23072020NMZS

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Site:

• Site ID:

• Survey date:

  Date

• Email to send the report to:

• Employer:

• RPS:

• RPS Training: within last 5 years and since IRR17 came into force:

  Yes

  No

• Designation of controlled/supervised areas

  Inside the x-ray room

  2m Sphere

  None

• Occupancy concerns?

  Yes

  No

• Please note them here:

• MPE:

  Select Shahed Alan Niall

  • Shahed
  • Alan
  • Niall

• Is the RPA Shahed Khan?

  Yes

  No

  N/A

• Name of RPA:

• Perform Chargeable Risk Assessment for client:

  Y

  N

Sources of Radiation

• Select the source of radiation

  Select Veterinary X-Ray Chiropractic X-Ray Dental x-Ray

  • Veterinary X-Ray
  • Chiropractic X-Ray
  • Dental x-Ray

• Number of units

• Radon: Evidence of previous Radon monitoring / assessment

  YES

  NO

Equipment Details

• Generator

• Tube stand

• Tube

• Control panel

• Bucky stand

• LBD

• Tank

• Bucky trays

• Processor

• Battery pack

• Last Svc:

• CE Marked?

1.0 Radiation Protection

• 1.1 The X-Ray unit is used in a:

  dedicated x-ray room

  multi-purpose room

  open area

• Measuring approximately m x m

• 1.2 The walls are

  Shielded

  Brick/Block

  Stud

  Unknown

• Approximate Pb equiv (mm)

• Yes

  No

  N/A

• Approximate thickness (cm)

• 1.3 The entrance door has a functioning locking mechanism

  Yes

  No

• Indicating bolt advised?

  Yes

  No

• Door / Glazing shielded?

  Yes

  No

  N/A

• Note the Pb Equ in mm

• Access controlled by operator

  Yes

  No

• 1.4 Exposure switch has multiple controls

  Yes

  No

• Location of exposure button (s)

  Cable

  Console

  Wall

• Prevents Door Closure?

  Yes

  No

• >3 long?

  Yes

  No

• Operator is in a Protected area

  Yes

  No

• 1.5 Primary Method of Shielding:

  Distance

  Leaded Door

  Walls of the building

  Protective Screen

• How far (m)?

• How thick (mm Pb)?

• How thick (mm Pb)?

• 1.6 Lead rubber was provided?

  Yes

  No

• Integral to table

  Added underneath

  Bare lead

• 1.7 Is personal monitoring performed?

  Yes

  No

• Mirion

  Landauer

  PHE

  RRPPS

  Other

• Who?

• Past Doses

• 1.8 Is leaded PPE provided?

  Yes

  No

• Apron

• Quantity

• Thickness (mm Pb Equ)

• Storage

  Hung up

  Rail

  Hanger

  Heap

• Serviceable

  Yes

  No

• Screening records

  Yes

  No

• Gloves/mitts

• Quantity

• Thickness (mm Pb Equ)

• Storage

  Hung up

  Rail

  Hanger

  Heap

• Serviceable

  Yes

  No

• Screening records

  Yes

  No

• Thyroid shield

• Quantity

• Thickness (mm Pb Equ)

• Storage

  Hung up

  Rail

  Hanger

  Heap

• Serviceable

  Yes

  No

• Screening records

  Yes

  No

• Sleeves

• Quantity

• Thickness (mm Pb Equ)

• Storage

  Hung up

  Rail

  Hanger

  Heap

• Serviceable

  Yes

  No

• Screening records

  Yes

  No

• 1.9 Local Rules Condition

  Complete

  Incomplete

  Missing

• Location

  Select In room Out of room Loose In log

  • In room
  • Out of room
  • Loose
  • In log

• Up to date

  Yes

  No

• Officers details

  Select Employer RPA RPS

  • Employer
  • RPA
  • RPS

• 1.10 Warning Lights Present

  Yes

  No

• Appropriate?

  Yes

  No

• Controlled by separate switch?

  Yes

  No

• Functional?

  Yes

  No

• Notice present?

  Yes

  No

• Appropriate?

  Yes

  No

• Send a new sign?

  Yes

  No

• Pregnancy warning?

  Yes

  No

  N/A

• Needs relocating?

  Yes

  No

• 1.11 Scatter Survey performed?

  Yes

  No

• Exposure factors used?

2 Electro-Mechanical Condition

• 2.1 All major mechanical parts were found to be in a serviceable order:

  Yes

  No

• 2.2 Movement of the various parts were smooth:

  Yes

  No

• 2.3 Covers in good condition:

  Yes

  No

• Securely attached:

  Yes

  No

• 2.4 Tube stand / mount / ceiling track secure / height adjustment functional / movements smooth

  Yes

  No

• 2.5 X-ray tube (stand) stationary following positioning and release

  Yes

  No

• 2.6 Counterweighting: X-ray tube

  Slightly

  Over

  Under

  OK

  N/A

• Verticle Bucky

  Slightly

  Over

  Under

  OK

  N/A

• 2.7 Tube stand electro-mechanical brakes

  OK

  Not OK

  NA

• 2.8 Bucky stand electro-mechanical brakes

  OK

  Not OK

  NA

• 2.9 The x-ray tube apparently perpendicular to the table top.

  Y

  N

• 2.10 The x-ray table:

  Select Rigid Level Stationary Floating table-top

  • Rigid
  • Level
  • Stationary
  • Floating table-top

• 2.11 Tube – grid/bucky alignment:

  OK

  Not OK

  NA

• 2.12 The cassette tray

  Not retained within the bucky

  N/A

• 2.13 Collimator

  Select Integral to the housing Securely attached Slightly loose Rotated freely Fixed orientation Smooth Sticky Do Not Stay Open

  • Integral to the housing
  • Securely attached
  • Slightly loose
  • Rotated freely
  • Fixed orientation
  • Smooth
  • Sticky
  • Do Not Stay Open

• 2.14 The visible suspension components were seen to be:

  in a servicable order

  NOT in a servicable order

  N/A

• 2.15 Grids:

  Secure in bucky

  Removable

  Fits over cassette

• Grid size

• Ratio

• Frequency

• Interspace

• Focal length

• condition

• 2.16 Mains connection via:

  Isolator

  3-pin plug

  (into) switched fused spur

  Battery

• 2.17 Safe disconnect in emergency?

  Yes

  No

• 2.18 Phases

  1

  3

  Unknown

• 2.19 All controls and displays functioned correctly

  Yes

  No

• Strain reliefs OK

  Yes

  No

• 2.20 All visible cables were sound

  Yes

  No

• 2.21 The earth wiring present?

  Yes

  No

• Under tension?

  Yes

  No

• 2.22 The locking retaining rings for the HT cables are:

  Slightly loose

  Secure

  N/A

3. Image Processing

• 3.1 Ventilation adequate.

  Yes

  No

• 3.2 Image processing/capture was provided by the use of:

  Film

  Plate reader

  DR

• 3.3 This was sitting on an appropriate:

  Stand

  Surface

  Unit

  Floor standing

  N/A

• 3.4 Developer temperature °C

• 3.5 The films were adequately fixed

  Yes

  No

• Washed

  Yes

  No

• 3.6 The rollers were in a reasonable condition

  Yes

  No

• 3.7 House keeping: send darkroom chart

• Processor cleaning dates

• Roller cleaning dates

• Cassette cleaning dates

• Chemicals changed dates

• Sensitometry dates

• Chemistry stored appropriately

  Yes

  No

• 3.8 The chemical waste is:

  Plumbed to drains via a silver recovery trap

  Waste bottles

• 3.9 A drip tray is advisable to protect film

  Yes

  No

• Film type

• Colour

• Stored upright

• Screen ISO

• Screen Colour

• Cleanliness OK

• Cassette lightproof

  Yes

  No

• Safelight

  Yes

  No

• Appropriate

  Yes

  No

• Housing leaking?

  Yes

  No

• Light-proofing

  Yes

  No

• 3.10 Safe handling time

• 3.11 Optical density on the test film was reasonable

  Yes

  No

• 3.3 This was sitting on an appropriate:

  Stand

  Surface

  Unit

  Floor standing

  N/A

• 3.12 Exposure index unit (DDI)

  None

  S value

  EI

  LGM

  Other

• Details

• 3.13 Cassette storage

  Select N/A Along-dide Under reader In cupboard Requires improvement

  • N/A
  • Along-dide
  • Under reader
  • In cupboard
  • Requires improvement

• 3.14 Range of appropriate processing algorithms

  Yes

  No

• 3.15 Cassette artefacts

  Yes

  No

• 50 kV, 0.5 mAs @75cm (or aim for 20 µGy)

• Small (18 x 24) sensitivity

• Date started

• DI @ centre

• Medium (24 x 30) sensitivity

• undefined

• Date started

• DI @ centre

• Large (35 x 43) / ( 30/40/) sensitivity

• Date started

• DI @ centre

• 3.16 Any image artefacts due to objects in the beam path

  Yes

  No

• Pleate damage?

  Yes

  No

• Reader?

  Yes

  No

• Dust/dirt?

  Yes

  No

• Scratches/Pickoff

  Yes

  No

• Scum?

  Yes

  No

• Screens?

  Yes

  No

4. Radiographic Practice

• 4.1 Operators appropriately trained

  Yes

  No

• 4.2 Holding procedures performed?

  Yes

  No

• Holders documented?

  Yes

  No

• PPE from holding procedures seen on images?

  Yes

  No

• 4.3 Record keeping uses:

  Book

  Loose sheets in folder

  On PC

  Other

• Give details

• Time period audited: Has been kept up tp date

  Yes

  No

• Full details of every radiograph

  Yes

  No

• # Exposures in logbook

  Yes

  No

• Patient measurement/weight

  Yes

  No

• Exposure grading

  Yes

  No

• # Exposure recorded on computer

  Yes

  No

• 4.4 The estimated average exposure (kV, mAs & cm)

• 4.5 Exposure chart:

  Select No Comprehensive Appropriate Displayed on wall Logbook Manual

  • No
  • Comprehensive
  • Appropriate
  • Displayed on wall
  • Logbook
  • Manual

• 4.6 L & R indicators available?

  Yes

  No

• Demonstrated appropriately

  Yes

  No

• 4.7 Are the following available

  Select Cradles Wedges Sandbags Tie downs Callipers Filters Compression belts Gonad shields

  • Cradles
  • Wedges
  • Sandbags
  • Tie downs
  • Callipers
  • Filters
  • Compression belts
  • Gonad shields

• 4.8 Patient identity:

  Select Not done Digital Light marker Xrite tape Permanent marker Label

  • Not done
  • Digital
  • Light marker
  • Xrite tape
  • Permanent marker
  • Label

• 4.9 The reviewed images displayed consistently diagnostic densities

  Yes

  No

• 4.10 Optimal exposure determinations Y/N

  Yes

  No

• Extremes of range displayed

• Most in the range

• 4.11 Techniques were determined to be consistent

  Yes

  No

• 4.12 Artefacts demonstrated on the reviewed images

  Select No Regularly Occasionally Clothing

  • No
  • Regularly
  • Occasionally
  • Clothing

• 4.13 Split films

  Not seen

  Occassional

  Regularly

• 4.14 Collimation and positioning: Consistent?

  Yes

  No

• Appropriate?

  Yes

  No

• Positioning

  Good

  Fair

  Poor

  N/A

• Centring

  Good

  Fair

  Poor

  N/A

• Demonstrated 3 or 4 borders

  Yes

  No

• Add comments

5. Equipment performance

• Yes

  No

  N/A

• Distance tape accurate to within 1cm?

  Yes

  No

  N/A

• Timer

  Yes

  No

  N/A

• Controls operating correctly

  Yes

  No

  N/A

• Early release Terminates?

  Yes

  No

  N/A

• Displays operating correctly

  Yes

  No

  N/A

• Continue or restart exposure

  Yes

  No

  N/A

• Focal spot position marked

  Yes

  No

  N/A

• Measured?

  Yes

  No

  N/A

• Early release: Alarm

  Yes

  No

  N/A

• HVL Recorded

  Yes

  No

  N/A

• Value?

• Repeatability

  Yes

  No

  N/A

• measurements taken

  Yes

  No

  N/A

• AV indication of exposure

  Yes

  No

  N/A

• Set vs measured kV

• operating as expected

  Yes

  No

  N/A

• mA Linearity

• mAs Linearity

• kV and DR waveforms obtained setting

  Yes

  No

  N/A

• Radiation - light film taken

  Yes

  No

  N/A

• Erasure Efficiency+ EI

  Yes

  No

  N/A

• Calliper check 5cm / 18cm

  Yes

  No

  N/A

• Limiting resolution (lp/mm)

• Plate transport check

  Yes

  No

  N/A

• TO.20 exposure

  Yes

  No

  N/A

• Dental: Beam circular?

  Yes

  No

  N/A

• Dental: Beam central to cone?

  Yes

  No

  N/A

• LAT lumbar spine: The current UK national Diagnostic Reference Level (DRL) is 10mGy (2.5Gy.cm2)

• Measured dose (mGy)

• Measured distance (cm)

• Pt. Thickness (cm)

• Clinical FFD (m)

• 

• Therefore entrance skin dose = (mGy)