Download Page 1 of 4 Computed Tomography (CT) Plan Review Data Sheet

TM
Computed Tomography (CT)
Plan Review Data Sheet
Facility Name:
Facility Address (include city, state & zip code):
Facility Contact and Title:
Contact Phone Number:
Contact Fax Number or email:
Mailing Address (include city, state & zip code):
Facility Type:
New facility for registration with state
Existing facility registration with state
Relocation of existing registered facility
Installation Type:
Additional Equipment
Replacement Equipment
Relocating Equipment**
New – First Time - Equipment
** Relocating From Address:
1.
** Relocating To Address:
2.
Unit Make/Model:
Maximum kVp value for unit:
Maximum mA value for unit:
Page 2 of 4
CT Workload Information (please indicate preference):
I am referencing a workload of
mA-min/week contained on a previous CT shielding
report (must be for the same CT unit with the same radiation scatter profile) that I have determined
is representative of the workload necessary for this application.
I elect to provide specific technique data for each type of exposure (complete technique weekly
workload worksheet below) along with a radiation scatter plot for the CT unit.
CT Weekly Workload Worksheet
CT Scan Type
CT Scan length (cm)
CT Scans per week with and without contrast
scans per week
% with contrast
CT Scan Type
CT Scan length (cm)
CT Scans per week with and without contrast
scans per week
% with contrast
CT Scan Type
CT Scan length (cm)
CT Scans per week with and without contrast
scans per week
% with contrast
CT Scan Type
CT Scan length (cm)
CT Scans per week with and without contrast
scans per week
% with contrast
CT Scan Type
CT Scan length (cm)
CT Scans per week with and without contrast
scans per week
% with contrast
Page 3 of 4
Interior wall
Coverings (not the frame) are made of :
1.
wood
gypsum
concrete
2. The thickness of the wall covering is
Exterior wall
Coverings (not the frame) are made of :
1.
wood
gypsum
concrete
2. The thickness of the wall covering is
other (specify)
inches.
other (specify)
inches.
Floor & Ceiling Information
Single story structure – ground below and sky above the imaging room
Only roof above the imaging room
Only ground below the imaging room
1. Above Room
a. The space above is used as a
b. The distance from the floor of the imaging room to the floor above is
c. The floor above is composed of
with a minimum thickness of
inches.
2. Below Room
a. The space below is used as a
b. The distance from the floor of the imaging room to the floor below is
c. The floor below is composed of
with a minimum thickness of
inches.
Room Drawing – must contain all of these elements
1.
2.
3.
4.
5.
6.
The drawing must be scaled so that it is in proportion
A horizontal and a vertical dimension must be present so the scale can be verified (faxing can
distort the scale)
The position and orientation of the imaging unit and any imaging receptors
The proposed location of the control switch
Proposed method for operator to view the patient
The facility layout within a 45’ radius from the imaging room (this can be a separate drawing).
Terms of Service
1.
2.
3.
4.
5.
The plan review service is offered at a rate of $300.00 per room evaluation.
Revisions of a completed report due to omission of pertinent information or incorrect information
are completed at a rate of $150.00 per hour not to exceed two hours.
A plan review report cannot be issued unless we have all information required to complete the
report.
All information submitted must be legible.
ProPhysics Innovations is not responsible for obtaining or providing information being requested
on the application.
Page 4 of 4
6.
7.
Any additional information, not requested on the application, but incidental to the performance of
the service is subject to items 3-5 of these terms.
The report is a recommendation only, based on industry standards and state regulation.
Payment Method
Credit Card (Visa, Discover, MasterCard and Government Credit Cards are accepted)
In order to accept payment via credit or debit card, we will need the following information:
Cardholder’s Name:
Cardholder’s Billing Address:
City:
State:
Zip:
Credit Card Number:
Expiration Date:
/
3-digit Security Code (located on back of card):
To make payment via telephone please call 800.835.3615
You may fax payment information to 919.465.2544
Please forward the completed form and drawing(s) to ProPhysics at
[email protected] or fax (919)465-2544.