As you complete this form, here are some things to keep in mind:

• If there are units in more than one room, please fill out a form for each room. The reports are written separately, so it is helpful for us to have individual applications.
• Please indicate the maximum number of exposures or scans the room needs to be shielded for during a 40-hour work week for each applicable imaging mode.
• Consider growth in x-ray use over time to assure adequate shielding as modifications to the room can be costly in terms of material and additional physics service fees.
• The facility radiation safety officer is ultimately responsible and liable for evaluating and providing the workload estimate used to shield the public and staff.
• All workloads submitted by an agent or employee of the facility are assumed to have been reviewed and approved by the facility’s radiation safety officer.
• LANDAUER Medical Physics is not able to calculate specific shielding requirements without appropriate radiation scatter information for the CT or CBCT model’s imaging modes.