4 Facility Certification Document

Facility Certification Document

Reset Form

Form Approved OMB No. 0920-0020

NIOSH
Coal Workers' Health Surveillance Program
1095 Willowdale Rd.
Morgantown, WV 26505
Telephone Number

Facility Name
Street Address
City

State

County

Zip Code

Type of Facility (Mobile, Clinic, Private Office, Hospital, ...)
X-Ray Units (Use N/A for does not apply)

How many chest x-rays per year?
Unit #1

Unit #2

Generator Manufacturer
Model
Date Acquired
Max. kVp / Max mA

kVp

mA

cm

Source to Film/Detector Distance

kVp

in

cm
Three

Phase

Single

Pulse? (If Three Phase)

Yes

No

Yes

No

Battery Powered?

Yes

No

Yes

No

Capacitor Discharge?

Yes

No

Type Anode

Rotating

Yes
No
Rotating

Grid Used?

Yes

Three

Single

Stationary
No

Yes

mA

in

Stationary

No

Grid Manufacturer
Type

Stationary

Moving

Stationary
cm

Ratio / Lines per unit
Air Gap Used?

Yes

Digital System Type

CR

No

in

cm
Yes

DR

Moving

CR

in

No
DR

Manufacturer
Model
System Serial #
Software Version
Installation Date
Detector Size (cmXcm)
Image matrix (megapixels)
PACS Manufacturer
Last Radiation Inspection By / Date
Deficiencies and Date Corrected

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

Qualifications

I agree to participte in this program in the manner specified by Part 37 of 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 physician in charge

Signature

Date

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.