Form Rx14 - Computerized Tomography Page 2
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3MARYLAND DEPARTMENT OF THE ENVIRONMENT
●
1800 Washington Boulevard
Baltimore Maryland 21230
●
●
(410) 537-3193
1-800-633-6101
Regulation
Pass (P), Fail
Number
Requirement for CT Imaging Procedures and Equipment
Or Not Applicable
(NA)
F.11(d)(1)
Survey performed as required
Yes
No
/
/
Date of last Survey:
Name of person or service company performing survey:
____________________________________________________________
F.11(d)(2)(iii)
Instrumentation dosimetry calibration within two (2) years?
Yes
No
F.11(d)(2)(v)
CTDI or Multiple Scan Average Dose (MSAD) measurement/calibration
available for each type of scan performed?
Yes
No
Dose Phantom used: (Head) Mfr./Model____________________________
F.11(d)(2)(vii)
Calibration procedures available in writing?
Yes
No
F.11(d)(3)(i)
Dose measurement, spot-check procedures written, and performed by
qualified expert?
Yes
No
Name of person or service company performing dose measurement:
____________________________________________________________
F.11(d)(2)(vi)(c) Spot-check performed at required interval
Yes
No
/
/
Date of spot-check:
Person performing Spot-check:
Licensed Inspector, Lic. No. __________
Registered Service Company:
Name ____________________________________Reg. No. __________
F.11(d)(3)(ii)
Spot-check incorporates use of facility use factors and approved phantom
Yes
No
If not, specify equivalent (Mfr. & Model etc.) _______________________
F.11(d)(3)(iv)
Images from spot-check retained in two forms, photographic and digital
P
F
N/A
F.11(d)(4)(ii)
Information available at the control panel for operation and calibration:
(a) Dates of the latest calibration/spot checks posted at control panel
P
F
N/A
(b) Instructions available on the use of the CT dosimetry phantom(s)
P
F
N/A
(c) Distance available between tomographic plane and reference plane in
millimeters
P
F
N/A
(d) Current technique chart available to specify routine exams, techniques,
P
F
N/A
scans/exam
F.11(d)(4)(iii)
If spot-check tolerance has been exceeded, have limitations been specified?
Yes
No
If Yes, briefly describe written limitations:
____________________________________________________________
Author of recommended limits: _____________________________
Reg. No/Lic. No. _______________
Form Number
MDE/ARMA/COM.010
(MDE
Page 2 of 3
RX14) Revision Date 6/15/16
Recycled Paper
TTY Users 1-800-735-2258
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