Form Rx14 - Computerized Tomography
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3MARYLAND DEPARTMENT OF THE ENVIRONMENT
●
1800 Washington Boulevard
Baltimore Maryland 21230
●
●
(410) 537-3193
1-800-633-6101
MDE RX14
COMPUTERIZED
TOMOGRAPHY
/
MDE Machine Number
System/Tube S.N. ________________________
-
Facility Registration Number
Facility Name ___________________________
/
/
Begin Inspection
Inspector License No. _____________________
mm
dd
yy
Manufacturer ________________________________
Model _________________________________
Maximum kVp, MA, Scan Time (sec) ____ ____/____ Gantry Manufactured after 9/3/85
Y
N
Date Manufactured _________________
Single Tomogram per Scan
Multiple Tomogram: ____ per scan. Overlap ____mm.
Regulation
Pass (P), Fail
Number
Requirement for CT Imaging Procedures and Equipment
Or Not Applicable
(NA)
F.11(b)(1)
(i) Means provided to terminate the x-ray exposure in event of data
collection failure
P
F
N/A
(ii) A visible signal indicates when the x-ray exposure is terminated
P
F
N/A
(iii) Operator can terminate the x-ray exposure at any time
P
F
N/A
F.11(b)(2)(i)
F.11(b)(2)(ii)
Visual determination of the tomographic or reference plane?
P
F
N/A
F.11(b)(3)(i)
Visual indication at the control and gantry when x-rays are produced?
P
F
N/A
F.11(b)(3)(ii)
Emergency termination switch available?
Yes
No
Emergency termination switch clearly labeled?
P
F
N/A
F.11(b)(4)
Condition of operation to be used during a scan or scan sequence
is indicated
P
F
N/A
F.11(b)(6)
Angular position shall be identified
P
F
N/A
F.11(b)(7)
(i) Total error of indicated vs. measured at scan plane: _____
(must be <5mm)
P
F
N/A
(iii) Return to indicated start position? (must be + 1 mm): _____
P
F
N/A
F.11(c)(1)
Two-way aural communication provided
P
F
N/A
F.11(c)(2)(i)
Continuous operator observation of the patient during exposures provided
P
F
N/A
F.11(c)(2)(ii)
If primary viewing system electronic, alternate system for observation of
the patient during exposures provided
P
F
N/A
Form Number
MDE/ARMA/COM.010
(MDE
Page 1 of 3
RX14) Revision Date 6/15/16
Recycled Paper
TTY Users 1-800-735-2258
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