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Above Table X-Ray Source Fluoroscopic _ Spot Film Systems Field Test Record Template

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Above Table X-Ray Source Fluoroscopic _ Spot Film Systems Field Test Record Template Powered By Docstoc
					                           DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                       FIELD TEST SERIAL NO: (1-8)
                                    PUBLIC HEALTH SERVICE                                                            Print Legibly. Use Black
                                FOOD AND DRUG ADMINISTRATION
                                                                                                                     Ball Point Pen. Enter One           AF
                                ABOVE TABLE X-RAY SOURCE                                                                                                 REGIONAL REVIEW (NAME)
                           FLUOROSCOPIC AND SPOT FILM SYSTEMS                                                        Character per Box. Do Not
                                   FIELD TEST RECORD                                                                 Write in Shaded Area.
              (Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)

Card         Test
No.          Procedure:                   Component Certification Information
(9-10)       1.                           2.
                                               Indicate the status of each as follows:
                  AF                                  C -- Certified                                          V -- Certified with a Variance
                  11      13
                                                      N -- Not Certified                                      X -- Not Present


                                                      Image Intensifier                                                    Fluoroscopic Imaging Assembly
                                               14     (after 4/77)                                                   15    (before 4/77)




            Surveyor Protection and Tracking Tests

                                                                                              3. System Hazardous                          Y -- Yes      N -- No
                                                                                                                                  16
                                                                                                   If yes, describe hazard in remarks and discontinue testing!
                                                             2   1
                                                             3   4                                                                                                                       Y -- Yes
                                                                                              4. Beam Limiting Device Tracks Image Receptor Property                                     N -- No
                                                                                                                                                                               17        X -- N/A
                                                                                                   Worst Case SID                               in OR                           cm



            X-Ray Field/Image Receptor Alignment


 20
                                      MDF (Exposure)
                                                                                    5. Source to TABLETOP
                                                                                            Distance
                                                                                                                                                         18
                                                                                                                                                                                     .     21
                                                                                                                                                                                                  cm


                                                                                   Image Dimension                                                                    X-Ray Field Dimension

                                                                          1 /4
                                                                                   6.

                                                                                         22
                                                                                                          .     24
                                                                                                                      in    BLD positioned at
                                                                                                                            worst case SID. Data
                                                                                                                                                               10.

                                                                                                                                                                          25
                                                                                                                                                                                          .     27
                                                                                                                                                                                                         cm

                                                                                                                            here only if answer
                                                    2 1
                                                    3 4                   2 /1
                                                                                   7.

                                                                                         28
                                                                                                          .     30
                                                                                                                      in
                                                                                                                            to tracking question
                                                                                                                            (#4) is "No".
                                                                                                                                                               11.

                                                                                                                                                                          31
                                                                                                                                                                                          .     33
                                                                                                                                                                                                         cm
                                                                                                                            Otherwise, proceed
                                                                          3 /2
                                                                                   8.

                                                                                         34
                                                                                                          .     36
                                                                                                                      in
                                                                                                                            with data at 14
                                                                                                                            through 22.
                                                                                                                                                               12.

                                                                                                                                                                          37
                                                                                                                                                                                          .     39
                                                                                                                                                                                                         cm

                  Insert loaded plastic
                  cassette after centering
                  test strand.
                                                                          4 /3
                                                                                   9.

                                                                                         40
                                                                                                          .     42
                                                                                                                      in
                                                                                                                                                               13.

                                                                                                                                                                          43
                                                                                                                                                                                          .     45
                                                                                                                                                                                                         cm



            Fluoro Control
                                                                                   14. Source to TABLETOP
                                                                                            Distance
                                                                                                                                                         46
                                                                                                                                                                                     .     49
                                                                                                                                                                                                  cm


             23.
                       Fluoroscopic Technique                             1 /4
                                                                                   15.
                                                                                                          .           in    Only part of test
                                                                                                                                                               19.
                                                                                                                                                                                          .              cm
                       Factor Control Type                                               50                     52          that requires                                 53                    55


                                56
                                                                          2 /1
                                                                                   16.

                                                                                         57
                                                                                                          .     59
                                                                                                                      in
                                                                                                                            magnification
                                                                                                                            mode. Take out
                                                                                                                            of this mode after
                                                                                                                                                               20.

                                                                                                                                                                          60
                                                                                                                                                                                          .     62
                                                                                                                                                                                                         cm


              M -- Manual Only                                            3 /2
                                                                                   17.

                                                                                         63
                                                                                                          .     65
                                                                                                                      in
                                                                                                                            completing the
                                                                                                                            test.
                                                                                                                                                               21.

                                                                                                                                                                          66
                                                                                                                                                                                          .     68
                                                                                                                                                                                                         cm

              A -- Automatic Only

              B -- Both Manual And Automatic
                                                                          4 /3
                                                                                   18.

                                                                                         69
                                                                                                          .     71
                                                                                                                      in
                                                                                                                                                               22.

                                                                                                                                                                          72
                                                                                                                                                                                          .     74
                                                                                                                                                                                                         cm



            Entrance Exposure rate (BLD fully open, no magnification, remove slide assembly)

             24.
                       MINIMUM Source to TABLETOP Distance
                                                                                                                     11
                                                                                                                                       .   14
                                                                                                                                                    cm
                                                                                                                                                           End of BLD as close to
                                                                                                                                                           30 centimeters as possible.

 21               MANUAL       25.

                                     15             17
                                                          kVp
                                                                             26.

                                                                                        18
                                                                                               .     19
                                                                                                              mA
                                                                                                                            27.

                                                                                                                                  20
                                                                                                                                                .         23
                                                                                                                                                                 R/min


             28. Is a high level control present?                                            Y -- Yes            29. Continuous Audible Signal Upon                            Y -- Yes
                                                                                                                                                                                              X -- N/A
                                                                                 24          N-- No                  Activation of High Level Control                25        N-- No


         FORM FDA 3069 (10/80)                                                                  Page 1 of 2 pages                                               Created by: PSC Media Arts Branch (301) 443-2454   EF
                     DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                              FIELD TEST SERIAL NO: (1-8)
                              PUBLIC HEALTH SERVICE                                                   Print Legibly. Use Black
                          FOOD AND DRUG ADMINISTRATION
                                                                                                      Ball Point Pen. Enter One           AF
                         ABOVE TABLE X-RAY SOURCE                                                                                         REGIONAL REVIEW (NAME)
                    FLUOROSCOPIC AND SPOT FILM SYSTEMS                                                Character per Box. Do Not
                            FIELD TEST RECORD                                                         Write in Shaded Area.
          (Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)

        Entrance Exposure rate (Continued)

          AUTO          30.

                              26           28
                                                 kVp
                                                                  31.

                                                                         29
                                                                                 .     30
                                                                                              mA
                                                                                                                32.

                                                                                                                      31
                                                                                                                                .          34
                                                                                                                                                R/min


         33. Is a high level control present?                                    Y -- Yes          34. Continuous Audible Signal Upon                         Y -- Yes
                                                                                                                                                                         X -- N/A
                                                                        35       N-- No                Activation of High Level Control             36        N-- No


        X-Ray Field/Spot Film Size Comparison
21
         35. TABLETOP to SPOT-FILM PLANE Distance
                                                                                                                                    37
                                                                                                                                                .        39
                                                                                                                                                               cm


         36. Film Dimension Along Table
                                                                                            40
                                                                                                      .    42
                                                                                                                 in        OR
                                                                                                                                    43
                                                                                                                                                .        45
                                                                                                                                                               cm


         37. Film Dimension Across Table
                                                                                            46
                                                                                                      .    48
                                                                                                                 in        OR
                                                                                                                                    49
                                                                                                                                                .        51
                                                                                                                                                               cm


         39. Light Field Along Table
                                                             52
                                                                             .    54
                                                                                         cm
                                                                                                                 39. Light Field Across
                                                                                                                     Table
                                                                                                                                                     55
                                                                                                                                                                    .    57
                                                                                                                                                                               cm


        REMARKS




     FORM FDA 3069 (10/80)                                                             Page 2 of 2 pages

				
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