Olympic Health Physics
Login
Menu
Home
About Us
Why Choose Olympic Health Physics?
Our Team
Physicist Credentials
Services
Medical Physics
Health Physics
Radiation Shielding Design
USP 825 Compliance
Accreditation Support
MRI Safety
Radiation Dose Optimization
Education & Training
Live Seminars
Online Training
Client Education Portal
Resources
Resources & Forms
Safety Manuals
Rad Pro Calculator
Blog
Articles
Videos
Contact Us
Client Login
Radiation Shielding Design Request Form
Step
1
of
4
25%
LinkedIn
This field is for validation purposes and should be left unchanged.
Please complete this form for each room requested.
Room Type
Please Select Room Type
Radiographic
Fluoroscopic
Radiographic & Fluoroscopic
Computed Tomography (CT)
Interventional Radiology
Cath Lab
C-Arm
Dental
Chiropractic
Veterinary
PET/CT
SPECT/CT
Nuclear Medicine
DEXA
Mammography
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
Email
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
Select files
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
F-18
Other
Average Injected Activity (mCi)
Average Incubation Time (min)
Average Scan Time (min)
Nuclear Medicine Component
Procedure Types
General Nuclear Medicine
Nuclear Cardiology
General Nuclear Medicine & Nuclear Cardiology
General Nuclear Medicine & I-131 Therapy
General Nuclear Medicine, Nuclear Cardiology, and I-131 Therapy
Other
Please Describe
Estimated Maximum Number of Nuclear Medicine Patients per Week
Please Enter the PRIMARY Radioisotope Used
Tc-99m
Tl-201
I-123
I-131
Ga-67
In-111
Ra-223
Other
Average Activity (mCi)
Average Scan Time (min)
Percentage of Procedures Using Tc-99m
Please Enter the SECONDARY Radioisotope
Tc-99m
Tl-201
I-123
I-131
Ga-67
In-111
Ra-223
Other
None
Average Activity (mCi)
Average Scan Time (min)
CT
Type of CT Use
Diagnostic CT
CT Simulator (Radiation Therapy)
PET/CT
SPECT/CT
Veterinary CT
Other
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
Diagnostic CT
Veterinary
CT Simulator (Radiation Therapy)
PET/CT
SPECT/CT
Other
Please Describe
Maximum kVp
Radiographic
Estimated Maximum Number of Radiographic Patients per Week
Type of Radiographic Use
General X-Ray Room
Chest Room
R/F Room
Veterinary
Chiropractic
Other
Please Describe
Maximum kVp
Average mAs
Average Number of Exposures per Patient
Will a Chest Bucky and Table Bucky be Installed?
Chest Bucky Only
Table Bucky Only
Chest and Table Bucky
Imaging Type
CR
DR
Film
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
General Fluoroscopy
Cardiac Cath
Pain Clinic
Interventional Radiology
C-Arm
GI Lab
Other
Please Describe
Maximum kVp
Average Fluoroscopy Time per Exam
Dental
Type of Dental Use
Intraoral
Panoramic
CBCT
Other
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
New Construction
Remodel of Existing Building
Remodel of Existing Shielded Room
Equipment Replacement
Other
Is There a Previous or Existing Shielding Design for this Space?
No
Yes
Don't Know
Please Describe
Please Upload the Previous Shielding Design in PDF Format.
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 128 MB, Max. files: 2.
Is This a Multiple Story Building?
No
Yes
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?
No Occupied Space Above or Below
Above Only
Below Only
Above & Below
What is Above?
What is Below?
Please upload a scale (1/4") drawing of the room in PDF format.
Drop files here or
Select files
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).