Radiation Shielding Assessment – PCi Physics Consultants inc

Radiation Shielding Assessment Form

Are you looking for a radiation shielding assessment for a dental unit?(Required)

Example: Intraoral, Panoramic, PanCeph, CBCT. To proceed, please click either Yes or No.

Yes

Please use the Dental Radiation Shielding Assessment Form

Please go back and select the Dental Radiation Shielding Assessment link from the website page.

Physical Address of Equipment Install

ATTENTION: YOU WILL NEED the following items before completing this form: 1.) Drawing and dimensions of the room where unit is or will be installed. 2.) Surrounding rooms or areas and their functions (e.g., office, exam room, waiting area). 3.) Above and below areas and their functions (e.g., attic, basement, office space, storage). 4.) Door and window placement in room where unit is or will be installed. 5.) Wall, floor and ceiling composition and thickness (e.g., 5/8” sheetrock, 6” concrete). 6.) Placement of the X‐ray machine and exam table or dental chair within the room. 7.) Location of the controls or control booth for the unit. 8.) For CT units we need the Radiation Scatter Diagram from your CT Manufacturer

Facility Name(Required)

Facility Physical Address(Required)

Please enter the physical address where the unit is located.

Street Address City State ZIP Code

Contact Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Please provide the email address you wish to have the report sent to when completed.

Equipment Information

Please choose one of the below descriptions.(Required)

This is a new unit being installed in a newly constructed room.

This is a replacement unit for an existing room with no remodeling.

This is a replacement unit for an existing room with reconfiguration of space or some remodeling.

Other

Dental Unit Type(Required)

Please choose the type of dental unit requiring a radiation shielding assessment.

Equipment Type(Required)

Please choose the type of room or unit requiring a radiation shielding assessment.

Location of Unit(Required)

Please indicate the room number or name where this unit will be installed.

Number of patients per week(Required)

In an average week, how many patients will be scheduled on this unit?

Number of Pan/Ceph Patients Per Week(Required)

In an average week, how many patients will be scheduled for X-rays on this unit?

Pan Patients per week

Ceph Patients per week

Number of Pan/Ceph Exposures Per Patient(Required)

How many exposures will you take per patient?

Pan Exposures Per Patient

Ceph Exposures Per Patient

Number of Rad/Fluoro Patients Per Week(Required)

In an average week, how many patients will be scheduled for X-rays on this unit?

Rad Patients per week

Fluoro Patients per week

Number of Rad/Fluoro Exposures Per Patient(Required)

How many exposures will you take per patient?

Rad Exposures Per Patient

Fluoro Exposures Per Patient

Number of PET CT Patients Per Week(Required)

In an average week, how many patients will be scheduled for this room?

CT Patients per week

PET Patients per week

PET or Nuclear Medicine Activity(Required)

What is the average administered activity (mCi) per patient?

Number of CBCT Patients Per Week(Required)

In an average week, how many patients will be scheduled for X-rays on this unit?

Pan Patients per week

CT Patients per week

Number of CBCT Exposures Per Patient(Required)

How many exposures will you take per patient?

Pan Exposures

CT Exposures

What is the average kVp for Pan/Ceph?(Required)

Please list the average kVp setting per exposure.

Pan average kVp setting

Ceph average kVp setting

What is the average mA for Pan/Ceph?(Required)

Please list the average mA setting per exposure.

Pan average mA setting

Ceph average mA setting

Average time for Pan/Ceph?(Required)

Please list the average time for an exposure. DO NOT submit a range of times.

Pan average time setting

Ceph average time setting

What is the average kVp for Pan CBCT?(Required)

Please list the average kVp setting per exposure.

Pan average kVp setting

CT average kVp setting

What is the average mA for Pan CBCT?(Required)

Please list the average mA setting per exposure.

Pan average mA setting

CT average mA setting

What is the average time for Pan CBCT?(Required)

Please list the average time for an exposure. DO NOT submit a range of times.

Pan average time per exposure

CT average time per exposure

Please list the Manufacturer and the Model of the Unit(Required)

The name of the manufacturer and the model of the unit is required.

Manufacturer

Model

What is your average kVp setting?(Required)

Please list the average kVp setting per exposure.

Average mA setting?(Required)

Please list the average mA setting per exposure.

Average time per exposure?(Required)

Please list the average time for an exposure. DO NOT submit a range of times.

Floor and Ceiling(Required)

Please indicate the function of the area above and below the X-ray unit (e.g., attic, basement, office space, storage), and the thickness of the material in the ceiling and floor.

Above the X-ray area

Below the X-ray area

Ceiling material and thickness

Floor material and thickness

Walls(Required)

Please indicate the material and thickness of the walls in the room surrounding the X-ray unit.

Wall composition and thickness

A scale drawing of the X-Ray room must be submitted that includes ALL of the following:

Drawing and dimensions of the room
Compass rose indicating cardinal direction North
Surrounding rooms or areas and their functions (e.g., office, exam room, waiting area)
Door and window placement in room
Placement of the X-Ray machine and exam table within the room
Location of the controls or control booth
CT units require a scatter diagram from the vendor

For PET CT and CT units, a scatter diagram from the vendor is required. For PET CT, the drawing must include uptake/injection room(s) and PET specific restrooms.

For mobile, portable and handheld units, a scale drawing of each room the unit will be used in--and approximate placement of the unit in use in each room--is required. This includes off site locations such as hospital operating rooms.

Upload Documents

Upload Scale Drawing of Rooms and Scatter Diagram for CT unit.

Drop files here or

Max. file size: 512 MB.

Comments