Form Rx5 - Machine Data Healing Arts-General
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1MARYLAND DEPARTMENT OF THE ENVIRONMENT
●
1800 Washington Boulevard
Baltimore Maryland 21230
●
●
(410) 537-3193
1-800-633-6101
ARMA-MDE RX5
MACHINE DATA
HEALING ARTS-GENERAL
Mfr. ______________________
Date Manufactured _______________
Model ____________________
Location __________________
MDE Machine No. ___________
Tube S.N. _______________________
Facility Reg. No. __________________
Facility Name _______________________________
Begin Inspection ____________
Inspector No. _____________
mm
dd
yy
Regulation
Pass (P), Fail (F),
Number
Description
Not Applicable (NA)
F.3(a)(1)(iii)
Adequate technique charts shall be posted.
P
F
N/A
F.3(a)(1)(iv)
Special safety instruction shall be posted where required.
P
F
N/A
F.3(a)(1)(v)
Protective apparel shall be available as appropriate.
P
F
N/A
F.3(a)(1)(vi)
Gonad shielding shall be available.
P
F
N/A
F.3(a)(1)(vii)
Thyroid shielding shall be available.
P
F
N/A
F.3(a)(1)(ix)
For auxiliary support, mechanical holding devices are
P
F
N/A
available when appropriate.
F.3(a)(1)(x)
Procedures and auxiliary equipment to minimize patient and
P
F
N/A
personnel exposure shall be utilized.
F.3(a)(1)(xi)
Personnel working with x-ray systems must follow protocol
P
F
N/A
and abide by requirements in Section D.
F.4(a)
Warning labels shall be legible, accessible to view, and
P
F
N/A
posted on the control panel.
F.4(b)
A charge indicator shall be present on battery powered
P
F
N/A
machines.
F.4(f)
There shall be an indication of the selected tube (for multiple
P
F
N/A
tubes).
F.4(g)
The tube head shall be adequately supported.
P
F
N/A
F.4(h)
The technique factors shall be indicated at the control panel.
P
F
N/A
F.3(a)(3)(ii)
If human holders are used, the name of the human holder
P
F
N/A
shall be recorded in a retrievable format.
Are certain names appearing routinely on the human holder
Yes
No
N/A
record?
Are all components federally certified?
Yes
No
Form Number MDE/ARMA/PER.028 (RX5)
Page 1 of 1
Revision Date 5/10/16
Recycled Paper
TTY Users 1-800-735-2258
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