2.11 Radiographic Facility Certification

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 6

OMB: 0920-0020

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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 ___________________

Shape1 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




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