Form 2.11 Radiographic Facility Certification

Attachment 6 – Radiographic Facility Certification Document – Form 2.11
RADIOGRAPHIC FACILITY CERTIFICATION DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH							Form Approved OMB No. 0920-0020 Exp.Date xx/xx/20xx NIOSH Coal Workers' Health Surveillance Program 1095 Willowdale Road, M/S LB208 Morgantown, WV 26505 Fax: 304-285-6058
Facility Name ______________________________________________________________								Telephone Number ___________________
Street Address ____________________________________________ Email
City ________________________		State ______		Zip Code _________		County __________________________
Type of Facility (Mobile, Clinic, Private Office, Hospital, …) ___________________________								How many chest x-rays per year? _______
Radiograph Units (Use N/A for does not apply)			Unit #1					Unit #2
NIOSH Facility Number - Unit Number			____________________________________					____________________________________
Room Number			____________________________________					____________________________________
Generator Manufacturer			____________________________________					____________________________________
Model			____________________________________					____________________________________
Date Acquired			____________________________________					____________________________________
Max kVp / Max mA			__________ kVp / ____________ mA					__________ kVp / ____________ mA
Source of Film/Detector Distance			____________  cm  in					____________  cm  in
Phase			 Single  Three					 Single  Three
Pulse?			 Yes  No					 Yes  No
Battery Powered?			 Yes  No					 Yes  No
Capacitor Discharge?			 Yes  No					 Yes  No
Type Anode			 Rotating  Stationary					 Rotating  Stationary
Grid Used?			 Yes  No					 Yes  No
Grid Manufacturer			____________________________________					____________________________________
Type			 Stationary  Moving					 Stationary  Moving
Ration / Lines per unit			__________/ ___________  cm  in					__________/ ___________  cm  in
Air Gap Used?			 Yes  No					 Yes  No
Digital System Type			 CR  DR					 CR  DR
Manufacturer			____________________________________					____________________________________
Model			____________________________________					____________________________________
System Serials #			____________________________________					____________________________________
Software Version			____________________________________					____________________________________
Installation Date			____________________________________					____________________________________
Detector Size (cmXcm)			____________________________________					____________________________________
Image matrix (megapixels)			____________________________________					____________________________________
PACS Manufacturer			____________________________________					____________________________________
Last Radiation Inspection By / Date			_______________________/_____________					_______________________/_____________
Deficiencies and Date Corrected
Name(s) and Qualifications of Radiograph Technologist(s)
____________________________________			____________________________________					____________________________________
____________________________________			____________________________________					____________________________________
____________________________________			____________________________________					____________________________________
I agree to participate 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 treated in a secure manner and will not be disclosed, unless otherwise compelled by law.
___________________________ Name of physician in charge	_______________________________ Email Address				_____________________________ 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 7-24, Atlanta, GA, 30333 ATTN:PRA (0920-0020). Do not send the completed form to this address.
CDC 2.11 (E), Rev. 01/2015