Title Page

  • Conducted on

  • Prepared by

  • Location
  • Site:

  • Site ID:

  • Survey date:

  • Email to send the report to:

  • Employer:

  • RPS:

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

  • Designation of controlled/supervised areas

  • Occupancy concerns?

  • Please note them here:

  • MPE:

  • Is the RPA Shahed Khan?

  • Name of RPA:

  • Perform Chargeable Risk Assessment for client:

Sources of Radiation

  • Select the source of radiation

  • Number of units

  • Radon: Evidence of previous Radon monitoring / assessment

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:

  • Measuring approximately m x m

  • 1.2 The walls are

  • Approximate Pb equiv (mm)

  • Approximate thickness (cm)

  • 1.3 The entrance door has a functioning locking mechanism

  • Indicating bolt advised?

  • Door / Glazing shielded?

  • Note the Pb Equ in mm

  • Access controlled by operator

  • 1.4 Exposure switch has multiple controls

  • Location of exposure button (s)

  • Prevents Door Closure?

  • >3 long?

  • Operator is in a Protected area

  • 1.5 Primary Method of Shielding:

  • How far (m)?

  • How thick (mm Pb)?

  • How thick (mm Pb)?

  • 1.6 Lead rubber was provided?

  • 1.7 Is personal monitoring performed?

  • Who?

  • Past Doses

  • 1.8 Is leaded PPE provided?

  • Apron

  • Quantity

  • Thickness (mm Pb Equ)

  • Storage

  • Serviceable

  • Screening records

  • Gloves/mitts

  • Quantity

  • Thickness (mm Pb Equ)

  • Storage

  • Serviceable

  • Screening records

  • Thyroid shield

  • Quantity

  • Thickness (mm Pb Equ)

  • Storage

  • Serviceable

  • Screening records

  • Sleeves

  • Quantity

  • Thickness (mm Pb Equ)

  • Storage

  • Serviceable

  • Screening records

  • 1.9 Local Rules Condition

  • Location

  • Up to date

  • Officers details

  • 1.10 Warning Lights Present

  • Appropriate?

  • Controlled by separate switch?

  • Functional?

  • Notice present?

  • Appropriate?

  • Send a new sign?

  • Pregnancy warning?

  • Needs relocating?

  • 1.11 Scatter Survey performed?

  • Exposure factors used?

2 Electro-Mechanical Condition

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

  • 2.2 Movement of the various parts were smooth:

  • 2.3 Covers in good condition:

  • Securely attached:

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

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

  • 2.6 Counterweighting: X-ray tube

  • Verticle Bucky

  • 2.7 Tube stand electro-mechanical brakes

  • 2.8 Bucky stand electro-mechanical brakes

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

  • 2.10 The x-ray table:

  • 2.11 Tube – grid/bucky alignment:

  • 2.12 The cassette tray

  • 2.13 Collimator

  • 2.14 The visible suspension components were seen to be:

  • 2.15 Grids:

  • Grid size

  • Ratio

  • Frequency

  • Interspace

  • Focal length

  • condition

  • 2.16 Mains connection via:

  • 2.17 Safe disconnect in emergency?

  • 2.18 Phases

  • 2.19 All controls and displays functioned correctly

  • Strain reliefs OK

  • 2.20 All visible cables were sound

  • 2.21 The earth wiring present?

  • Under tension?

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

3. Image Processing

  • 3.1 Ventilation adequate.

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

  • 3.3 This was sitting on an appropriate:

  • 3.4 Developer temperature °C

  • 3.5 The films were adequately fixed

  • Washed

  • 3.6 The rollers were in a reasonable condition

  • 3.7 House keeping: send darkroom chart

  • Processor cleaning dates

  • Roller cleaning dates

  • Cassette cleaning dates

  • Chemicals changed dates

  • Sensitometry dates

  • Chemistry stored appropriately

  • 3.8 The chemical waste is:

  • 3.9 A drip tray is advisable to protect film

  • Film type

  • Colour

  • Stored upright

  • Screen ISO

  • Screen Colour

  • Cleanliness OK

  • Cassette lightproof

  • Safelight

  • Appropriate

  • Housing leaking?

  • Light-proofing

  • 3.10 Safe handling time

  • 3.11 Optical density on the test film was reasonable

  • 3.3 This was sitting on an appropriate:

  • 3.12 Exposure index unit (DDI)

  • Details

  • 3.13 Cassette storage

  • 3.14 Range of appropriate processing algorithms

  • 3.15 Cassette artefacts

  • 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

  • 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

  • Pleate damage?

  • Reader?

  • Dust/dirt?

  • Scratches/Pickoff

  • Scum?

  • Screens?

4. Radiographic Practice

  • 4.1 Operators appropriately trained

  • 4.2 Holding procedures performed?

  • Holders documented?

  • PPE from holding procedures seen on images?

  • 4.3 Record keeping uses:

  • Give details

  • Time period audited: Has been kept up tp date

  • Full details of every radiograph

  • # Exposures in logbook

  • Patient measurement/weight

  • Exposure grading

  • # Exposure recorded on computer

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

  • 4.5 Exposure chart:

  • 4.6 L & R indicators available?

  • Demonstrated appropriately

  • 4.7 Are the following available

  • 4.8 Patient identity:

  • 4.9 The reviewed images displayed consistently diagnostic densities

  • 4.10 Optimal exposure determinations Y/N

  • Extremes of range displayed

  • Most in the range

  • 4.11 Techniques were determined to be consistent

  • 4.12 Artefacts demonstrated on the reviewed images

  • 4.13 Split films

  • 4.14 Collimation and positioning: Consistent?

  • Appropriate?

  • Positioning

  • Centring

  • Demonstrated 3 or 4 borders

  • Add comments

5. Equipment performance

  • Distance tape accurate to within 1cm?

  • Timer

  • Controls operating correctly

  • Early release Terminates?

  • Displays operating correctly

  • Continue or restart exposure

  • Focal spot position marked

  • Measured?

  • Early release: Alarm

  • HVL Recorded

  • Value?

  • Repeatability

  • measurements taken

  • AV indication of exposure

  • Set vs measured kV

  • operating as expected

  • mA Linearity

  • mAs Linearity

  • kV and DR waveforms obtained setting

  • Radiation - light film taken

  • Erasure Efficiency+ EI

  • Calliper check 5cm / 18cm

  • Limiting resolution (lp/mm)

  • Plate transport check

  • TO.20 exposure

  • Dental: Beam circular?

  • Dental: Beam central to cone?

  • 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)

  • Screenshot 2020-03-30 at 16.50.52.png
  • Therefore entrance skin dose = (mGy)

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