Quality Medical Health Physics in the Pacific Northwest

Shielding Intake Form

Name and Address of Facility Being Shielded:

Facility Name: / Room ID:
Practitioner: / Contact:
Address: / Phone:
City/State/Zip: / E-mail:

Fluoroscopic System Information:

Manufacturer: / Model:
Type of fluoro system (i.e. fluoro used in radiology, special C-arm, mobile C-arm, Cardiac Cath, Angiography, pain management, etc.):
Maximum number of patients imaged per week:
Average Fluoro time per exam:

Room Layout:

  1. Are the walls of the x-ray room all standard gypsum wallboard construction? □ Yes □No

If any walls contain material other than standard gypsum wallboard construction, please specify the composition and thickness (i.e. 6-inch concrete) and indicate on the floor plan which walls contain the materials.

  1. Is this a single-story building (nothing above or below the x-ray room)? □ Yes □No

If space above the x-ray room is occupied, please provide:

Description of how the space above is used
Floor-to-floor distance (floor of the x-ray room to the floor of the room above)
Floor composition and thickness (i.e. 3 inches of concrete)

If the space below the x-ray room is occupied, please provide:

Description of how the space below is used
Floor-to-floor distance (floor of the x-ray room to the floor of the room below)
Floor composition and thickness (i.e. 3 inches of concrete)
  1. Please attach a drawing (on a separate page) of the room that includes all of the following elements (Please see attached example floor plans):
  2. Room dimensions (length and width of the room).
  3. Equipment layout (where the equipment will be located in the room, including the control area, chest bucky, and/or table imaging receptor).
  4. Surrounding areas (please show on the floor plan the areas beyond all the adjacent walls of the x-ray room and label how they will be used – i.e. hallway, office, parking lot, landscaping, etc.).
  1. Payment information. Please call (360) 736-6066 to provide credit card payment information. Work on the design will not begin until payment is received.

Send Report to: / Billing Address:
Facility Name:
Attn:
Address:
City/State/Zip:

If possible, please email the above information to Lisa at .

You may mail the above information to Corwin Health Physics at PO Box 1707, Centralia, WA 98531

P.O. Box 1707 Phone: (360) 736-6066

Centralia, WA 98531 Fax: (360) 736-7293