0920-24IK Radiographic Facility Certification Form

RADIOGRAPHIC FACILITY CERTIFICATION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

NIOSH
Coal Workers' Health Surveillance
Program 1000 Frederick Lane, M/S LB208
Morgantown, WV 26508
Fax: 304-285-6058

Form Approved
OMB No.: 0920-0020

Facility Name ______________________________________________________________
Street Address ____________________________________________

City ________________________

State ______

Email

Zip Code _________

County __________________________

Type of Facility (Mobile, Clinic, Private Office, Hospital, …) ___________________________
Radiograph Units (Use N/A for does not apply)

Telephone Number ___________________

How many chest x-rays per year? _______

Unit #1

Unit #2

NIOSH Facility Number - Unit Number

____________________________________

____________________________________

Room Number

____________________________________

____________________________________

Generator Manufacturer

____________________________________

____________________________________

Model

____________________________________

____________________________________

Date Acquired

____________________________________

____________________________________

Max kVp / Max mA
Source of Film/Detector Distance

__________ kVp / ____________ mA
____________  cm  in

__________ kVp / ____________ mA
____________  cm  in

Phase

 Single

 Three

 Single

 Three

Pulse?

 Yes

 No

 Yes

 No

Battery Powered?

 Yes

 No

 Yes

 No

Capacitor Discharge?

 Yes

 No

 Yes

 No

Type Anode

 Rotating

 Stationary

 Rotating

 Stationary

 Yes

 No

 Yes

 No

Grid Used?
Grid Manufacturer

____________________________________

____________________________________

Type

 Stationary

 Stationary

Ratio / Lines per unit

 Moving

 Moving

__________/ ___________  cm  in

__________/ ___________  cm  in

Air Gap Used?

 Yes

 No

 Yes

 No

Digital System Type

 CR

 DR

 CR

 DR

Manufacturer

____________________________________

____________________________________

Model

____________________________________

____________________________________

System Serials #

____________________________________

____________________________________

Software Version

____________________________________

____________________________________

Installation Date

____________________________________

____________________________________

Detector Size (cmXcm)

____________________________________

____________________________________

Image matrix (megapixels)

____________________________________

____________________________________

PACS Manufacturer

____________________________________

____________________________________

Last Radiation Inspection By / Date

_______________________/_____________

_______________________/_____________

Deficiencies and Date Corrected
Name(s) and Qualifications of Radiograph Technologist(s)
____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

I agree to participate in this program in the manner specified by Part 37 of the Code of Federal Regulations (42 CFR Part 37), and understand that all information
used in connection with this program will be treated in a secure manner and will not be disclosed, unless otherwise compelled by law.

___________________________
Name of physician in charge

_______________________________
Email Address

_____________________________
Signature

_________________
Date

Public reporting burden of this collection of this information is estimate to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer,
1600 Clifton Road, MS H21-8, Atlanta, GA, 30333 ATTN:PRA (0920-0020). Do not send the completed form to this address.
CDC/NIOSH 2.11 (M), Rev. 03/2021

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