Free 3069 - Federal

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

FIELD TEST SERIAL NO: (1-8)

ABOVE TABLE X-RAY SOURCE FLUOROSCOPIC AND SPOT FILM 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.

AF
REGIONAL REVIEW (NAME)

Card No.
(9-10)

Test Procedure: 1.

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

AF
11 13

C -- Certified N -- Not Certified
Image Intensifier (after 4/77)

V -- Certified with a Variance X -- Not Present
Fluoroscopic Imaging Assembly (before 4/77)

14

15

Surveyor Protection and Tracking Tests 3. System Hazardous 16
2 3 1 4

Y -- Yes

N -- No

If yes, describe hazard in remarks and discontinue testing! 4. Beam Limiting Device Tracks Image Receptor Property Worst Case SID in OR 17 cm Y -- Yes N -- No X -- N/A

X-Ray Field/Image Receptor Alignment MDF (Exposure) 5. Source to TABLETOP Distance Image Dimension 1 /4
2 1 3 4

20

18

.
10. 25 11. 31 12. 37 13.

cm

21

X-Ray Field Dimension
in

6. 22

2 /1

7. 28

3 /2 Insert loaded plastic cassette after centering test strand.

8. 34

4 /3

9. 40

. . . . . . . .

24
in

30
in

36
in

BLD positioned at worst case SID. Data here only if answer to tracking question (#4) is "No". Otherwise, proceed with data at 14 through 22.

42

43

. . . . . . . . .
49

cm

27
cm

33
cm

39
cm

45
cm

Fluoro Control
23.

14. Source to TABLETOP Distance 1 /4 15. 50 2 /1 56 16. 57 3 /2 17. 63 4 /3 18. 69

46

19.
in

Fluoroscopic Technique Factor Control Type

52
in

59
in

M -- Manual Only A -- Automatic Only B -- Both Manual And Automatic

Only part of test that requires magnification mode. Take out of this mode after completing the test.

cm

53 20. 60 21. 66 22.

55
cm

62
cm

65
in

68
cm

71

72

74

Entrance Exposure rate (BLD fully open, no magnification, remove slide assembly)
24.

MINIMUM Source to TABLETOP Distance 11

.
27.

cm

14

End of BLD as close to 30 centimeters as possible.
R/min

21

MANUAL

25. kVp

26.

15

17

18

.

mA

19

20

.

23 Y -- Yes N-- No X -- N/A

28. Is a high level control present? 24

Y -- Yes N-- No

29. Continuous Audible Signal Upon Activation of High Level Control

25

FORM FDA 3069 (10/80)

Page 1 of 2 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)

ABOVE TABLE X-RAY SOURCE FLUOROSCOPIC AND SPOT FILM 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.

AF
REGIONAL REVIEW (NAME)

Entrance Exposure rate (Continued) AUTO 30.
kVp

31. 26 28 29

.

32.
mA

30

31

.

R/min

34 Y -- Yes N-- No X -- N/A

33. Is a high level control present? 35

Y -- Yes N-- No

34. Continuous Audible Signal Upon Activation of High Level Control

36

21

X-Ray Field/Spot Film Size Comparison 35. TABLETOP to SPOT-FILM PLANE Distance 37 36. Film Dimension Along Table 40 37. Film Dimension Across Table 46 39. Light Field Along Table 52

. .

in

OR 43

42
in

OR 49

48

. . .

cm

39
cm

45
cm

51

.

cm

54

39. Light Field Across Table

55

.

cm

57

REMARKS

FORM FDA 3069 (10/80)

Page 2 of 2 pages