Free 2784 - Federal

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

FIELD TEST SERIAL NO. (1-8) Print Legibly. Use Black Ball Point Pen. Enter One Character Per Box. Do Not Write in Shaded Area.

AR
REGIONAL REVIEW (NAME)

ABOVETABLE X-RAY SOURCE RADIOGRAPHIC SYSTEMS FIELD TEST RECORD

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

Card No.
(9-10)

Test Procedure 1.

Beam Limiting Device Information 2. Manufacturer

Mfr. Code

AR
11 13
3.

14
Unique ID

17

Model No. Serial No.

18
Date of MFR Mo/Yr

23

24

36

37

40

X-Ray Table Information: 4. Manufacturer

Mfr. Code

41
Unique ID

44

10

5. Model No. Serial No.

45
Date of MFR Mo/Yr

50

51

67

68

71

Component Certification Information 6. Indicate the status of each as follows: C - Certified N - Not certified Beam Limiting Device V - Certified with a Variance X - Not Present Table Film Changer

72

73

74

75

Tube Housing Assembly

76

Cradle

77

Other (Specify in Remarks)

78

X-ray Controls

79

High Voltage Generator

Initial Setup: 7. Means To Indicate When Beam Axis Is Perpendicular to Image Receptor Plane Means To Center Diagnostic Source Assembly Over Image Receptor Y--YES N--NO

11

8.

9.

12
Indicated Source To image Distance (SID) Technique Factors
q

Y--YES N--NO OR cm

13

15

inches

q

16

19

S6
11
14. MDH (Pulse Exposure) 4.5mm Al MDH Threshold Setting, 0.5-3 phase, 0.2-1 phase

10.

20
11.

22

kVp

over 70 kV 12.

23
13.

26

mA

q

27

30

sec

ø

q

31

32

34

mAs

FORM FDA 2784 (10/80)

Page 1 of 3 pages

Created by: PSC Media Arts Branch (301) 443-2454

EF

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

FIELD TEST SERIAL NO. (1-8) Print Legibly. Use Black Ball Point Pen. Enter One Character Per Box. Do Not Write in Shaded Area.

AR
REGIONAL REVIEW (NAME)

ABOVETABLE X-RAY SOURCE RADIOGRAPHIC SYSTEMS FIELD TEST RECORD

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

Beam Quality 18.
q

15.

35

39
q

mR @ 4.5mm Al 16.

Technique Factors Indicated Before Exposure

40

Y--YES N--NO

11

19.

41
20.
q

45

mR @ 3.5mm Al

If Multiple Tubes Controlled By Single Exposure Switch, Then Indication Of Tube Selection Both At Control Panel And At Selected Tube Y--YES N--NO X--N/A

46
21.
q

50

mR @ 2.5mm Al 17.

51
Warning Label Present

52 22.

56

mR @ 1.5mm Al

57

Y--YES N--NO Y--YES N--NO

Exposure Terminated After Preset Time Interval, Preset mAs, Or Preset Number of Pulses

58

Reproducibility (no Al in beam) 23.
q

24.

33.

34.
q

11
25.
q

15

mR 26.

16

18

msec 35.

19
q

23

mR 36.

24

26

msec

12

27
27.
q

31

mR 28.

32

34

msec 37.

35
q

39

mR 38.

40

42

msec

43
29.
q

47

mR 30.

48

50

msec 39.

51
q

55

mR 40.

56

58

msec

59
31.
q

63 15

mR 32.

64 16

66 18

msec 41. msec

67
q

71 23

mR 42.

72 24

74 26

msec

11
Linearity 43. mA

mR

19

mR

msec

SID Determination 48. Distance from tabletop to focal spot 49.
q

13

27 30 If change in mA causes a kVp shift, readjust kVp (if possible) to value selected at Item 10 above.

31
q

34
cm

cm

Distance from UTIR to Base of Test Stand (Y)

35

37

44.
q

38
45.
q

42

mR

PBL X-Ray Field/UTIR Size Comparison 50. Film Dimension Along Table Film Dimension Across Table Indicated SID inches OR cm

q

q

43
46.
q

47

mR 51. mR 52. mR

48
q

50

51
q

53

59
q

61
inches

inches

OR

62
q

64

cm

54
47.
q

58

70

72

OR

73

76

cm

65
53. 54.

69

Type of Positive Beam Limitation (PBL)

A. Automatically Adjusts X-ray Field B. Prevents Production of X rays Until Manual Adjustments are Made C. Not Present (Explain in Remarks)

11
A, B, or C

Is the PBL Currently Operating in Conformance with its Design 55. Light Field Along Table 56.
q

12
Light Field Across Table

Y--YES

N--NO

14

13
57. Indicated SID

15
q

cm

q

16
inches 59. OR Light Field Across Table
q

18
cm

cm

19
58. Light Field Along Table
q

21
cm

22

25

q

26

28

29

31

cm

FORM FDA 2784 (10/80)

Page 2 of 3 pages

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

FIELD TEST SERIAL NO. (1-8) Print Legibly. Use Black Ball Point Pen. Enter One Character Per Box. Do Not Write in Shaded Area.

AR
REGIONAL REVIEW (NAME)

ABOVETABLE X-RAY SOURCE RADIOGRAPHIC SYSTEMS FIELD TEST RECORD

(Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)
PBL Sizing (Continued) 60. Film Dimension Along Table 61. Film Dimension Across Table 62. Indicated SID 63. Light Field Along Table
q q q

32

34

inches

OR

q

35
q

38

cm

39
inches

41

inches

OR

42
q

45
cm
q

cm

46
q

48

OR 64.

49

52 56

14
65.

53
q

55

cm

Light Field Across Table

58

cm

Indicated SID 66. Light Field Along Table

59
q

61

inches 67.

OR

q

62

65

cm

66

68

inches

Light Field Across Table

q

69

71

cm

PBL Operation: 68. In PBL Mode, Adjustment Possible To Field Size Smaller Than Image Receptor 69. Y--YES N--NO Automatic Return To PBL When Image Receptor Is Changed Y--YES N--NO N--NO

72

73
Y--YES

70. X-ray Production Prevented At SID's Where Operation Is Not Intended

74

Actual Versus Indicated Field Size 71. Beam Limiting Device Numerically Indicates Field Size 72. Y--YES N--NO Indicated SID inches OR cm

q

q

11

12
q

14

15
q

18
cm

73. Film Dimension Along Table 74. Film Dimension Across Table 75. Light Field Along Table
q

19 25
76.
q

21 27

inches

OR

22
q

24 30
q

inches

OR

28

cm

31

33

cm

Light Field Across Table

34

36

cm

Illuminance (uncorrected; SID = 42.5" (106 cm)) 77. 78.

=
total ambient

q

37
q

39

fc
total ambient

=
80.

q

40
q

42

fc

15

79.

=
total ambient

fc

=
total ambient

fc

43

45

46

48

X-Ray Field/Light Field Alignment and Size Comparison 81. 83. Light Field Along Table 85. Misalignment Along Table X-Ray Field Along Table 82.
q

cm

X-Ray Field Across Table

q

cm

49
q

51
cm

84. Light Field Across Table 86. cm Misalignment Across Table

52
q

54
cm

55
q

57

58
q

60
cm

61
X-Ray Field/UTIR Centers Comparison 87. Centers Misalignment

62

63

64

q

cm

65
Page 3 of 3 pages

66

FORM FDA 2784 (10/80)