Radiographic Room Shielding Information Sheet

CORWIN HEALTH PHYSICS INC

Quality Medical Health Physics in the Pacific Northwest Chiropractic Radiographic Room Shielding Intake Form

Name and Address of Facility Being Shielded: Facility Name: Room ID: Practitioner: Contact: Address: Phone: City/State/Zip: E-mail:

X-Ray System Information: What is the expected number of patients to be imaged per week? Will all images be taken in the vertical position (i.e. no tabletop exposures)? What type of system will be installed (CR, film, or DR)? If the system installed is film, do you expect to change to CR or DR in the near future?

Room Layout: 1. Are the walls of the x-ray room all standard gypsum wallboard construction? □ Yes □ No If any walls contain material other than standard gypsum wallboard construction, please specify the composition and thickness (i.e. 6-inch concrete) and indicate on the floor plan which walls contain the materials. 2. Is this a single-story building (nothing above or below the x-ray room)? □ Yes □ No If space above the x-ray room is occupied, please provide:

Description of how the space above is used Floor-to-floor distance (floor of the x-ray room to the floor of the room above) Ceiling composition and thickness (i.e. 3 inches of concrete)

If the space below the x-ray room is occupied, please provide: Description of how the space below is used Floor-to-floor distance (floor of the x-ray room to the floor of the room below) Floor composition and thickness (i.e. 3 inches of concrete)

P.O. Box 1707 Phone: (360) 736- 6066 Centralia, WA 98531 Fax: (360) 736-7293 CORWIN HEALTH PHYSICS INC

Quality Medical Health Physics in the Pacific Northwest

3. Please attach a drawing (on a separate page) of the room that includes all of the following elements (Please see example floor plan below.): a. Room dimensions (length and width of the room). b. Equipment layout (where the equipment will be located in the room, including the control area, chest bucky, and/or table imaging receptor). c. Surrounding areas (please show on the floor plan the areas beyond all the adjacent walls of the x-ray room and label how they will be used – i.e. hallway, office, parking lot, landscaping, etc.).

Exterior Wall (Parking)

Example Floor Plan

8' t m n o a o n R e t T

t 12 e n e m t c a a j e d r

A 11' T

Control Booth Area

Hallway

4. Payment information. Please call (360) 736-6066 to provide credit card payment information. Work on the design will not begin until payment is received. Send Report to: Billing Address: Facility Name: Attn: Address: City/State/Zip:

If possible, please email the above information to Lisa at [email protected]. P.O. Box 1707 Phone: (360) 736- 6066 Centralia, WA 98531 Fax: (360) 736-7293 CORWIN HEALTH PHYSICS INC

Quality Medical Health Physics in the Pacific Northwest

You may mail the above information to Corwin Health Physics at PO Box 1707, Centralia, WA 98531

P.O. Box 1707 Phone: (360) 736- 6066 Centralia, WA 98531 Fax: (360) 736-7293