Form Rx 4 - Inspection Data Facility Specific

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MARYLAND DEPARTMENT OF THE ENVIRONMENT
1800 Washington Boulevard
Baltimore Maryland 21230
(410) 537-3300
1-800-633-6101
MDE RX 4
INSPECTION DATA
FACILITY SPECIFIC
Facility Reg. No. ___________________
Facility Name_____________________________________________________
Date of Inspection ____________ Facility Representative_____________________________________________
Regulation
Pass (P), Fail (F),
Number
Description
Not Applicable (NA)
P
F
N/A
D.201
Allowable dose levels in restricted areas are within standards.
P
F
N/A
D.502 &
Records of personnel monitoring
D.1107
Type of personnel monitoring _____________________
Name of company providing service ___________________________
Highest 3 readings in past 3 months: mRem
period
______
____________________
______
____________________
______
____________________
P
F
N/A
D.301
Allowable dose levels for unrestricted areas are within standards.
Check which method is used:
(copy available and
P
F
N/A
B.4; F.3(a)(2)(viii)(b)
Department approved plan review ______
letter at facility)
(copy available and
P
F
N/A
D.302
Department approved area survey ______
letter at facility)
P
F
N/A
J.11(a)(2)
Current registration form must be posted.
P
F
N/A
J.11(c)
Form “Notice to Employees” posted.
F.3(d)
Machines must be maintained per manufacturer's specs,
and documentation of this maintenance must be maintained
P
F
N/A
and submitted to the Agency
Machine MDE No. ______ Latest Maintenance Date ________ Service Provider Reg. No. __________
Machine MDE No. ______ Latest Maintenance Date ________ Service Provider Reg. No. __________
Machine MDE No. ______ Latest Maintenance Date ________ Service Provider Reg. No. __________
Machine MDE No. ______ Latest Maintenance Date ________ Service Provider Reg. No. __________
Machine MDE No. ______ Latest Maintenance Date ________ Service Provider Reg. No. __________
Machine MDE No. ______ Latest Maintenance Date ________ Service Provider Reg. No. __________
Use second page to list additional machines at facility.
B.5/B.9
Department of Health and Mental Hygiene Office of Health Care Quality license posted
for radiation machine facilities with cardiac catheterization labs, computed tomography
Yes
No
N/A
(CT) scanner, or linear accelerators.
Applicable Only to Therapy Facilities: Deviation logbook checked to ensure that
Yes
No
N/A
there were no unreported misadministrations.
Directive:
At this facility, all personnel who apply x-rays to humans for diagnostic
or therapeutic purposes are registered or certified by the Board of
Yes
No
N/A
Physician Quality Assurance.
COMAR 26.12.02(c)
At this facility, all machines currently certified
Yes
No
(if NO, indicate machine no. and explanation on RX 2)
Inspector No. _________
Form Number MDE/ARMA/COM.03 (MDE RX-4)
1
2
Page
of
Revision Date 5/5/2016
Recycled Paper
TTY Users 1-800-201-7165

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