Free 2783 - Federal

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION

FIELD TEST SERIAL NO. (1-8)

MOBILE RADIOGRAPHIC SYSTEMS FIELD TEST RECORD

(Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)

Print Legibly. Use Black Ball Point Pen. Enter One Character Per Box. Do Not Write in Shaded Area.

MR
REGIONAL REVIEW (NAME)

Card No.
(9-10)

Test Procedure 1. MR 11

Component Certification Information 2. Indicate the status of each as follows:

13

C - Certified N - Not Certified

V - Certified with a Variance X - Not Present

14 17

Beam Limiting Device

15 18

High Voltage Generator Tube Housing Assembly with Beam Limiting Device and High Voltage Generator

16 19

X-ray Controls with High Voltage Generator Other (Specify)

Tube Housing Assembly

X-ray Controls

20

3. Generator Type: F-fullwave; H-halfwave; C-Capacitor;

21

Test Setup MDH (Pulse Exposure) 4.5 mm Al

Technique Factors 4.
kVP

5. over 70 kV
mA

10
6.

22
q

24
sec OR

25

27
pulses

28
7.
q

31
mAs

32

34

35
Beam Quality:

38

Capacitor discharge equipment - use maximum mAs for kV selected.

S6

8.
q

mR

@

4.5 mm Al

39
9.
q

43
mR @ 3.5 mm Al

44
10.
q

48
mR @ 2.5 mm Al

49
11.
q

53
mR @ 1.5 mm Al

54
12. Warning Label Present

58
13. Exposure Terminated After Preset Time Interval Preset mAs, Or Preset Number of Pulses
Y - Yes N - No

59

Y - Yes

N - No

60

Reproducibility (no AI in beam) 14.
q

15.
mR msec

61
16.
q

65
17.
mR

66

69
msec

70
18.
q

74
19.
mR

75

78
msec

11

15
21.
q

16
mR

19
msec

11

20.

20

24
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25

28
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FORM FDA 2783 (10/80)

EF

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION

FIELD TEST SERIAL NO. (1-8)

MOBILE RADIOGRAPHIC SYSTEMS FIELD TEST RECORD

(Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)
Reproducibility (Continued) 22.
q

Print Legibly. Use Black Ball Point Pen. Enter One Character Per Box. Do Not Write in Shaded Area.

MR
REGIONAL REVIEW (NAME)

23.
mR

29
24.
q

33
mR

38
26.
q

42
mR

Data here if any of items 14, 16, 18 and 20 differ by more than 10 percent of the largest value.

msec

34
25.

37
msec

43
27.

46
msec

47
28.
q

51
29.
mR

52

55
msec

56
30.
q

60
31.
mR

61

64
mRm

65
32.
q

69
33.
mR

70

73
msec

11
Linearity 34.
mA

15

16
Illuminance (uncorrected; SID = 42.5" (106cm)) 39.
total ambient

19

=
q

20 22 If change in mA causes a kVp shift, readjust kVp (if possible) to value selected at item 4 above.
35.
q

fc

23

25
q

40.
total ambient

=
fc

26

28
q

41.
mR

=
fc total ambient

29

33
42.
q

34

36
q

12

36.
mR

=
fc total ambient

37
37.
q

41
mR

42

44

45
38.
q

49
mR

X-Ray Field/Light Field Alignment: 43. Length Misalignment
q

50

54
44.

cm

55
Width Misalignment
q

56
cm

57
Minimum Source To Skin Distance 45. Outside Separation of Image of Focal Spot Strips
q

58

cm

59
Standby Radiation: (Capacitor discharge equipment only) 46.
q

61

47.
mR min sec

62 REMARKS

66

67

68

69

CHECK IF CONTINUATION SHEET USED

FORM FDA 2783 (10/80)

Page 2 of 2 Pages