NEWYORKCITYDEPARTMENT

OF HEALTH
ANDMENTALHYGIENE OFFICEOF RADIOLOGICAL
HEALTH
RADIATION
EQUIPMENT
DIVISION
QUALITYASSURANCE
AUDIT

1. Nameof Facility: Zip Code:

DIBIA: Number:(_)
Telephone
Addressof Facility:

2. Registration
Number: Establishment
Type:
CAMISNumber:

3. Executive
Administrator
Informedof Inspection AuditInterview By:
Conducted
Name: Name(s):
Title: BadgeNumber(s):
Date:

AuditInterview With:
Conducted
Name:
Title:
Date:

Exitinterviewconducted
withmemberof Executive (afterconsultation
Administration withx-raymanager)
Name: ExitInterview By:
Conducted
Tirle: Name(s):
Date: BadgeNumbe(s):

4. TotalNumberof X-RayTubes TubesInspected:

SingletubeF/F combos
Twotube F/F combos
Radiographic
only
MobileC-arm
MobileRadiographic
Dental
Mammography
CT
Therapy
LinearAccelerator
BoneDensitometer
Other
Numberof Inoperative
x-raytubes:
Numberof functional
x-raytubes:

TotalNumberof X-RayTubesInspected:
RC 37 (Rev. 11/05)
 5. ORGANIZATION
TELEPHONE
NO.

A. Administrator/Exec.
Dir. tr
B. RadiationSafetyOfficer tr
C. Chief- Dept.of Radiology f,
D. Chief- Dept.of Dentistry tr
- X-RayDept.
E. Administrator f,
F. ChiefLRT tr
G. Directorof Radiation
Therapy tr
H. Diagnostic
Radiological
Physicist tr
l. X-RayRepairService tt
J. ChairmanQ/ACommittee tr
K. lndividual
responsible
for entire tr
Q/A Program tr
L. QC Technologists tr

6. A. Frequency Meetings
of Q/ACommittee
B. Dateof LastMeeting
C. Minutesprovidedandkeptfor 3 years YesE No tr

7. ProgramReview(Periodicretrospective -
reviewof A/C results,imagequalityandoperatorperformance
changesin the programinitiated).
Appropriate
Indicatemeetingsconductedand reportsprovidedwhichaddressall aspectsof programreview.

I RECORDS
QG Manual
a. the committee anddutiesin writing,including
organization
listof all currentmembers Yestr Notr
b. listof the individualsresponsible
for testing,lsupervising
and repairing or servicing
the equipment Yestr Notr
c. a listof the equipment
to be tested Yestr Notr
d. a listof the teststo be performed
andthe frequencyof
performance YesE Notr
of the procedures
e. a briefdescription to be usedfor
eachtest YesE Notr
f. limitsfor eachtest
the acceptability YesE Notr
g. a listof the equipment
to be usedfor eachtest Yestr Notr
h. sampleformsto be usedfor eachtest YesE Notr
i. protocolfor correction YesE Notr
j. reference
materials
andtheirlocation YesE Notr

RC 37 (Rev.11/05)
 Comments: 9. EquipmentRecords- Recordsshallbe maintained
for eachx-rayroom
andmobilex-rayunitandinclude:

a. the initialtestresults(acceptance
testingand radiation
safetysurveyas required) YesE Notr
b. test resultsfor lastthreeyears YesE Notr
c. recordsof machinemalfunction
and repairfor last
threeyears YesE Notr
1 0 . EntranceSkin Exposuresfor commonx-rayexaminations
Thefacilityhasavailable
the biennialoutputmeasurements
for commonx-rayexaminations theyperform. Yes[ Notr
DataPosted Yestr Notr
1 1 .GalibrationRecordsfor TestEquipment
ForQC testequipmentwhichrequirescalibration,
records
maintainedandavailablefor review YesE Notr
12. RadiationSafetyPoliciesand Procedures
Thewrittenpolicyand procedures
mustbe availablefor:
a. holdingof patients YesE Notr
b. useof gonadalshielding Yestr Notr
c. scoliosisshieldingprocedures Yestr Notr
d. pregnantworkersand patients Yestr Notr
e. personnel
monitoring Yestr Notr
for perdiemor agencyemployees
f. monitoring YesE Notr
g. x-rayscreening YesE Notr
h. repeat,rejectanalysis YesE Notr
i. cassetteintegrityandscreenmaintenance YesE Notr

II EQUIPMENT
MONITORING
Comments: 13. EquipmentFunctioning
Daily fesfs
Indicatormalfunction,
mechanicalandelectrical
safetycheck(Appendix H N,YS,Guide) YesE No tr
14. Film Processor
Daily lesfs
1. (601)Densitometet Calibration
strip,Sensitometer
(ll or 21 step),provided. Yestr No tr N/Atr

2. (602)Thermometer,
Controlboxof filmand
ProcessorGraphsprovided. Yestr No tr N/Atr

3. (603)Densitometer, Thermometer
Sensitometer,
maintainedin goodrepair. YesE No tr N/Atr

4. (604)Appropriate
lightsettingon sensitometer
utilized. YesE No tr N/Atr

5. (605)Annualcheckof sensitometer
consistency
performed. Yestr No tr N/Atl

RC 37 (Rev.11/05)
 Comments: | 6. (606)Initialcontrolvaluesdetermined
afterPM of
processor. YesE No tr N/Atr

7. (607)Controlvaluesproperlyestablished
when
newcontrolbox of film is required. Yestr No tr N/Atr

8. (608)Controlvaluesproperlycalculated(speed,
contrastand B+Faveragedfor 3 filmsx2 days) Yestr No tr N/Atr

9. (609)ControlspeedindexsteprecordedandO.D.
between1.0-1.5. Yesfl No tr N/Atr

10. (610)Controlcontrastvaluerecordedand properly

determined. Yestr No tr N/Atr

11. (611)ControlB+Fvaluesrecordedandascertained
in a propermanner. Yestr No tr N/Atr

12. (612)Controlprocessor recorded;

temperature
withinnormallyacceptedrange;anddetermined
by film manufacturer. Yestr No tr N/Atr

13. (613)Sensitometry datais runand plottedon each

day that patientradiographyis conducted. Yestr No tr N/Atr

14. (614)Speed,contrast,B+Fandtemperature
were
*' i
accuratelygraphed. Yesfl No tr N/An
J
j.

15. (615)Patientradiography discontinuedwhenquality

assuranceparameters exceedtolerancelevels;
evidenceof rechartingaftercorrections
weremade. Yestr No tr N/Atr

16. (616)PM actions,majorrepairs,replenishmentrates

andchemistrychangesdocumented on "Actionon
Processor"
form;routinePM conducted at least
every4 weeks. YesE No tr N/Atr

17. (617)Threemonth'sdailysensitometry strips

retained.(Filmsare dated,and speed,contrast
and B+Fvaluesare recordedon film). Yestr No tr N/Atr

18. (618)Processor Q/Agraphs,controlfilms

(includingcross-overfilms)andsensitometry
filmsretainedfromone inspection
reproducibility
cycleto the next. Yestr No tr N/Atr

19. (619)Backup(manual)systemprovidedwhen
computerized data
analysisof sensitometry
is employed. YesE No tr N/Atr

RC 37 (Rev. 11/05)
 Comments: 15. Radiographic Units
Quarterlyfesfs
a. lightfieldlx-rayfieldalignment YesE Notr
b. positivebeamlimitation (PBL) YesE Notr
c. x-rayfield/image receptoralignment YesE Notr
Semi-annualtests
d. timerreproducibility YesE Notr
e. timeraccuracy YesE Notr
f. kVpaccuracy Yestr Notr
g. mA linearity(mF/mAs) Yesfl Notr
h. exposureswitch Yestr Notr
i. interlocks YesE Notr
Annualfesfs
j. SID indicators YesE Notr
k. HalfValueLayer(HVL) YesE Notr

16. FluoroscopicUnits
Quarterlylesfs
a. lmagereceptor/x-ray - fluoroscopic
fieldalignment YesE Notr
b. lmagereceptor/x-ray - spotfilm
fieldalignment YesE Notr
Semi-annualtests
c. highcontrastresolution Yestr Notr
d. lowcontrastresolution YesE Notr
e. exposureswitch YesE Notr
t. interlocks YesE Notr
Annualfesfs
g. 5 minutetimer Yesfl Notr
h. HalfValueLayer(HVL) Yestr Notr
i. Averagefluoroscopic
exposurerate Yes[ Notr
j. Maximumfluoroscopicexposurerate YesE Notr
k. Tracking YesE Notr
l. Spotfilmreproducibility Yesfl Notr
m. Pediatric
fluoroscopic
exposurerate YesE Notr
n. Smalladultfluoroscopic
exposurerate Yestr Notr
o. Largeadultfluoroscopic
exposurerate Yestr Notr

17. DentalX-RayEquipment
a. Timers,exposureswitches, HVL, x-rayproduction
collimation,
indicators, annuallyrecordsprovided
evaluated YesE No tr

D e n t aFl i l m :S p e e d T y p eD _ E _ F _
b. Measurements madeto determine whetherskindoseis
consistent withFederalguidelines (annually) Yesfl No tl
c. Tubeheadstabilityevaluated(annually) Yestr Notr

18. TomographicEquipment
Semi-annualtesb
cut E level
a. Sliceor tomographic YesE Notr
b. Sliceor tomographic
cut thickness Yestr Notr
c. Uniformityof exposure Yestr Notr
d. Resolution YesE Notr

RC 37 (Rev.11/05)
 (CT)
TOMOGRAPHY
GoMPUTERTZED

YES NCI N'A ES NA NTA

1 . Facilitypatientscans conductedusing AnnualAdult and PediatricPatient
OnlyAxialScanMode trD tr Dose Evaluations
*Conducted forAdultHeadandAbdomen D tr tr
OnlyHelicalScanMode D D N *Conducted
BothHelicalandAxialMode t r n D for Pediatric
Abdomen
(if scanned) D tr tr
TechniqueChartsPostedand contain *Conducted usingpostedtechnique
(at minimum)the following: chartfactors D E D
Scan mode/kVp/mA/numberof slices/image
reconstructionAlgorithmfor:
**AdultHeadandAbdomen D trtr
**Pediatric
Abdomen D D D
AdultHeadandAbdomen t r t r t r **AdultHeadandAbdomen CTDI(weighted)
Pediatric
Abdomen D t r N
dosesare:
DailyQC Tests: WithinNYCGuidelines tr tr D
*CT NumberWater t r D O **CTDI(weighted) dosescompared with
*CT Noise a n D published
manufacturer's guidelines tr B D
*CT lmageUniformity Dtr tr **WasCTDIvol determined (helical
*CT lmageArtifact Dtr tr scansONLY) A tr tr
*Equipmentfunction/indicators/safety
7. On Installationof NewTube:
checks D t r tr
Wereall weeklyandmonthlytests
MonthlyQC Tests completed beforepatientclinicalscans
*HardCopyOutputDevice D t r A conducted? D B tr
*CT NumberScaleAccuracy trD tr Wereannualandsemiannual tests
*SlicePositioningAccuracyTests completedwithin30 daysof tube
**LightLocalization Accuracy trD tr replacement date? A E D
**TableMovement Accuracy D t r D
**SlicePositioning 8. On lnstallationof NewUnit:
AccuracyTests trtr e
*(SliceSensitivity
Profile)lmagedSlice
Determinationof the HVLfor CT tr D o
RadiationProtectionSurveyfor new
Thickness
**Conducted for axialmode D B t r CT room tr tr D
**Gonducted Wereall weeklyand monthlytests
for helicalmode trB tr
**Conducted for all clinically completedbeforepatientclinical
usedaxial
Beamsizesandhelicalpitches trtr D scansconducted? tr a D
Wereannualandsemiannual tests
5. SemiAnnualTests completed within30 daysof the new
*DoseProfileWidth t r D D installation
commencing patient
*SpatialResolution(HighContrast) atr tr CTscans? tr D tr
**Conductedfor axialmode n c o
**Conductedfor helicalmode B t r A
**Conductedfor standardand high
ContrastAlgorithms D C n
*SpatialResolution(LowContrast) I n t r
**Conductedfor axialmode trtr tr
**Conductedfor helicalmode o a t r

RC37 (Rev.11/05)
 Comments: | 20. RadiationProtectionSurveys& CalibrationReports
a. RadiationProtectionSurveysprovidedfor newinstallations
(obtaincopies) YesE No tr
b. Annualcalibrationreportsprovidedfor all x-raytherapy
units Yestr No tr
c. Annualcalibrationreportsprovidedfor all imageintensified
fluoroscopic
units YesE No tr

Note: reviewall requiredcalibrationreports.Obtain copies of

calibrationsfor units inspected.

21. Safelights(SemiAnnually) Yestr No tr

21a.View boxes (SemiAnnually) Yestr No tr

22. LeadAprons,Gloves& Drapes(SemiAnnually) Yestr No tr

23. Film/ScreenContact(Sampleof screensin usefor

over4 yearsshallbe evaluated
annually) Yestr No tr

24 Cassetteintegrity and screen maintenance

(Continuing
Basis) YesE No tr

25. TechniqueCharts.Eachx-rayunitshallhavean appropriate

chartposted
technique YesE No tr

26. Log Book or Equivalent(patient's

name,dateof exam,type
numberof viewstaken)
of examination, Yestr No tr

26a.Log Book for Holding(including to holder)

exposures Yestr No tr

27. RepeaUReject Analysis

a. Conductsat leastone rejectanalysisperyearof their
x-raydepartment. YesE No tr
b. An ongoingrepeatanalysisis conducted at least
quarterly. Yestr No tr
c. Correctivemeasuresinitiated Yestr No tr

28. TrainingPrograms A trainingprogramfor all personnel

(lic.x-raytechs- aidesetc.)whoworkin or frequentany
controlled areamust be provided.lt shouldincludebut is
not limitedto:
a. workrules
b. potentialhazards(radiological, biological)
electrical,
c. emergency response
d. worker'srights
e. locationof pertinent documents
f. instruction devicesand interpretation
in the useof monitoring
of reports

Adequatetrainingprogramsprovided Yestr No tr

29. LicensedX-rayTechnologists
andtemporarylicensesposted.
All currentregistrations YesE No tr
Pocketlicensecarried(if checked). YesE No tr

RC 37 (Rev.11/05)
Comments: 30. Film BadgeReports
a. All reportsavailableand foundacceptable YesE Notr
b. Badgessubmittedin a timelyfashion Yestr Notr
c. All exposureswithinpermissiblelimits Yestr Notr
(considerAlaraguidelines)
d. Bureauof Rad.Healthnotifiedof reportable
overexposures. Yestr Notr
e. Badgessuppliedto requiredpersonnel Yesfl Notr
f. Personnel badgesstoredproperly Yestr Notr
g . Badgeswornin propermanner Yestr Notr
h . Filmbadgereportsreviewedby properpersonnel YesE No tl

EXPANDED
COMMENTS:

RC 37 (Rev.11/05)