CDC/NIOSH (M) 2.11 Facility Certification Document

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Form Approved OMB No.: 0920-0020

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOR NIOSH USE ONLY
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
FACILITY CERTIFICATION DOCUMENT
FOR NIOSH USE ONLY
NIOSH

RETURN COAL WORKERS' HEALTH SURVEILLANCE PROGRAM
PO Box 4258
TO
MORGANTOWN, WEST VIRGINIA 26504
Facility name

Telephone Number
City

Street Address

State

Type of Facility (Mobile, Clinic, Private Office, Hospital, etc.)

X-Ray Units (Separate section for each unit)
Model (Generator)
Manufacturer
Phase (Single, Three)

Processing (Manual, Machine)

Processing Time

Date Acquired MAX. kVp.

Ratio

Phase (Single, Three)

MAX. mA.

Model (Generator)

Lines Per
Inch

Manufacturer of Grid
Model

Deficiencies and Date Corrected

Date Acquired MAX. kVp.

MAX. mA.

Pulse (If Three Phase) Battery Powered? Capacitor Discharge

Grid Used Type (Stationary, Moving) Air Gap
Used
Processing (Manual, Machine)

Processing Time

Date of Last Radiation Inspection Inspected By

Source to Film
Distance

Type Anode (Tube Rotating, Stationary)

Manufacturer of Processor

Date of Last Radiation Inspection Inspected By

Manufacturer

County

Number of Beds Average Number of Chest X-Rays Taken Per
Month Last Year

Pulse (If Three Phase) Battery Powered? Capacitor Discharge

Grid Used Type (Stationary, Moving) Air Gap
Used

Zip Code

Ratio

Lines Per
Inch

Source to Film
Distance

Type Anode (Tube Rotating, Stationary)

Manufacturer of Grid

Manufacturer of Processor

Model

Deficiencies and Date Corrected
Qualifications

Name (s) of X-Ray Technologist (s)

I agree to participate in this program in the manner specified by Part 37 if the Code of Federal Regulations (42 CFR Part 37) , and understand that all
information used in connection with this program will be held STRICTLY CONFIDENTIAL and divulged only as specified by the above Regulation.

Name of M.D. in Charge

Date

Signature

CDC/NIOSH (M) 2.11 Rev. 07/2007
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, Project Clearance Officer, 1600
Clifton Road, MS D-24, Atlanta, GA, 30333 ATTN:PRA (0920-0020). Do not send the completed form to this address.

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