Radiation Shielding Design Request Form

Step 1 of 4

Please complete this form for each room requested.

Room Type

Please Select Room Type

Facility Contact Information

Facility Name

Room ID or Number

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Please complete this form for each room requested.

Contact Details

First Name

Last Name

Title

Company

Phone

Please complete this form for each room requested.

Equipment Information

Manufacturer

Model

Number of Slices for CT Scanner

Please Upload the Manufacturer Isodose Maps in PDF Format (if available).

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 2.

Equipment Workload

DEXA

Estimated Maximum Number of DEXA Patients per Week

Mammography

Estimated Maximum Number of 2D Mammography Patients per Week

Estimated Maximum Number of 3D Mammography Patients per Week

PET Component

Estimated Maximum Number of PET Patients per Week

How Many Days per Week Will PET Operate?

Primary PET Radioisotope

Average Injected Activity (mCi)

Average Incubation Time (min)

Average Scan Time (min)

Nuclear Medicine Component

Procedure Types

Please Describe

Estimated Maximum Number of Nuclear Medicine Patients per Week

Please Enter the PRIMARY Radioisotope Used

Average Activity (mCi)

Average Scan Time (min)

Percentage of Procedures Using Tc-99m

Please Enter the SECONDARY Radioisotope

Average Activity (mCi)

Average Scan Time (min)

CT

Type of CT Use

Please Describe

Estimated Maximum Number of CT HEAD Studies per Week

Estimated Maximum Number of CT BODY Studies per Week

Percentage of CT Procedures Using Contrast

Maximum kVp

CT Component

Percentage of SPECT Patients Receiving a CT

Estimated Maximum Number of CT HEAD Studies per Week

Estimated Maximum Number of CT BODY Studies per Week

Percentage of CT Procedures Using Contrast

Type of CT Use

Please Describe

Maximum kVp

Radiographic

Estimated Maximum Number of Radiographic Patients per Week

Type of Radiographic Use

Please Describe

Maximum kVp

Average mAs

Average Number of Exposures per Patient

Will a Chest Bucky and Table Bucky be Installed?

Imaging Type

Percentage of Time Chest Bucky is Used

Chest Bucky

Percentage of Time Table Bucky is Used

Table Bucky

Fluoroscopic

Estimated Maximum Number of Fluoroscopic Patients per Week

Type of Fluoroscopic Use

Please Describe

Maximum kVp

Average Fluoroscopy Time per Exam

Dental

Type of Dental Use

Please Describe

Estimated Maximum Number of Patients per Week

Estimated Maximum Number of Images per Week

Maximum kVp

Please complete this form for each room requested.

Construction Type

Is There a Previous or Existing Shielding Design for this Space?

Please Describe

Please Upload the Previous Shielding Design in PDF Format.

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 2.

Is This a Multiple Story Building?

Which Floor is the Room On?

What is the Floor to Floor Height?

Floor to Floor Height In Feet

What is the Floor / Ceiling Building Material?

(i.e., Wood, Concrete, GypCrete, etc)

What is the Floor / Ceiling Building Thickness?

Floor/Ceiling Thickness In Inches

Are There Occupied Spaces Above or Below?

What is Above?

What is Below?

Please upload a scale (1/4") drawing of the room in PDF format.

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 10.

Drawing should include the placement and orientation of equipment as well as surrounding spaces.

Describe the areas that are on the opposite sides of each wall (i.e., office space, work areas, hallways, bathrooms, etc).

This information may also be detailed on the floor map.

All walls are assumed to contain standard gypsum wallboard. If additional materials are known to be present, please list known compositions and thicknesses (i.e., 0.79 mm of lead, 8 inches of concrete).

Comments

This field is for validation purposes and should be left unchanged.