University of South Carolina s4

UNIVERSITY OF SOUTH CAROLINA Cabinet X-ray Equipment Inspection Form Date______RS #______Insp.______Investigator______Phone______Lab location______Person Contacted ______Equipment manufacturer______Model number ______Serial number______Posting and Labeling 1. "Caution- Radiation- This Equipment Produces Radiation When Energized" near "X-ray on" switch. (R.H.B. 7.5)______2. Permanently affixed label with max. kVp and mA, radiation symboland "Caution" logo. (R.H.B.7.5)______3. Caution: X-ray Equipment " or sign of similar intent posted on doors leading into the area. (R.H.B.7.12)_____ 4. RHA-20 "Notice To Employees" posted (R.H.B. 9.2.1)______5. Part 3 and Part 9 of "Title B" available (R.H.B. 9.2.1.)______Safety and Warning Devices 1. Key actuated control. (R.H.B.7.2 and 7.13.1.8.1)______2. Safety devices tested every 3 months and records kept (R.H.B. 7.9.1)______3. Maintenance records kept. (R.H.B.7.9.1)______4. If safety devices found to be defective, equipment disabled. (R.H.B.7.9.2)______5. Two interlocks provided. (R.H.B.7.13.1.6.1)______6. One interlock but not both is pressure sensitive and operated by the physical movement of the access door. (R.H.B.7.13.1.6.1)______7. All access panels are equipped with at least one interlock. (R.H.B. 7.13.1.6.2)______8. Use of x-ray control necessary to resume operation after interruption of exposure by interlock. (R.H.B.7.13.1.6.3)______9. Means to stop x-ray production other than interlock and main control switch. (R.H.B.7.13.1.8.2)______10. "X-ray On" light available. (R.H.B.7.13.1.8.3.)______11. Two independent means to indicate when x-rays are being generated. (R.H.B.7.13.1.8.3)______Area Requirements 1. Radiation survey performed: a. Upon installation and every 3 months.(R.H.B.7.13.1.1)______b. Following maintenance. (R.H.B.7.13.1.1)______c. Following repairs. (R.H.B.7.13.1.1)______2. Radiation emitted at a distance of 5 cm from the cabinet is less than .5 mR/hr. (R.H.B.7.13.1.3)______3. Permanent floor available for cabinet unit. (R.H.B.7.13.1.4)______Personnel Requirements 1. All operators completed basic x-ray safety course. (R.H.B.7.7.2)______2. Normal operating and emergency procedures written and available. (R.H.B.7.8)_____ 3. If required, personnel monitoring devices worn correctly. (R.H.B.7.10)______4. Maintenance performed by ______. ______Current Operators

1.______2.______3. ______4. ______Survey Results 1. kVp______2. mA______3. Readings______4. Survey meter: Manufacturer______Model______Serial______5. Last calibration______Variance requested______Date______Comments:

EHS-F-LEG-RAD-005 1 of 1 Issue Date: 7/24/02 Destroy Previous Revisions Reviewed: ______