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pdfRADIOGRAPHIC 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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File Type | application/pdf |
File Title | Radiographic Facility Certification |
Subject | Radiographic,Facility,Certification, The Facility Certification Document should be completed by any x-ray facility that wants to |
Author | DHHS/CDC/OD/OCOO/OCIO/MASO |
File Modified | 2025-01-16 |
File Created | 2012-05-22 |