Free 3261 - Federal

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

FIELD TEST SERIAL NO. (1-8)

VERTICALLY MOUNTED CASSETTE HOLDER 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.

VC
REGIONAL REVIEW (NAME)

Card No.
(9-10)

Test Procedure: 1.

Component Certification Information 2. Indicate the status of each as follows: C--Certified V--Certified with a Variance X--Not Present or Not Applicable High Voltage Generator 15 Tube Housing Assembly 17 X-ray Controls 20 18 Tube Housing Assembly with Beam Limiting Device 16 19 Vertical Cassette Holder Other (Specify)

VC
11 13

N--Not Certified Beam Limiting Device 14

10

3. Means To Center Diagnostic Source Assembly To The Image Receptor 21 Y--YES N--NO X--NOT APPLICABLE

Test Setup

S6

Technique Factors 4. Timer mode of operation during testing

5. 23 6. 26 28 25

kVp mA

Capacitor discharge equipmentuse maximum mAs for kV selected.

22 M--manually set time or mAs P--phototimer

7. 29 8. 36

.
32 mAs 38

sec OR 33 35

pulses

MDH (Pulse Exposure) 4.5 mm AI

Beam Quality 9. 39 10. 44 11. 49 12. 54

.
43

mR mR 48 mR 53 mR 58

@ @ @ @

4.5 mm AI 3.5 mm AI 2.5 mm AI 1.5 mm AI

. . .

13. Technique Factors Indicated Before Exposure 59

Y--YES N--NO

14. Exposure Terminated After Preset Time Interval, Preset mAs, Or Preset Radiation Exposure To Image Receptor

Y--YES 60 N--NO

Reproducibility 17. N--NO 19. 22 21. 31 23. 40 13

15. Warning Label Present Y--YES 11

.
17

mR mR 26 mR 35 mR 44

18. 18 20. 27 22. 36 24. 45 48 39 30 21

msec msec msec msec

. . .

11

16. MDH Threshold Setting, 0.5-3 phase, 0.2--1 phase

0

.
12
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FORM FDA 3261 (2/83)
EF

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

FIELD TEST SERIAL NO. (1-8)

VERTICALLY MOUNTED CASSETTE HOLDER RADIOGRAPHIC SYSTEMS FIELD TEST RECORD
(Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)
Reproducibility (Continued) 25.

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

VC
REGIONAL REVIEW (NAME)

11
27.

.
49 53

mR mR 62 mR 71 mR 15 mR 24 mR 33

.
58

Data Here If Any Of Items 17, 19, 21 And 23 Differ By More Than 10 Percent Of Largest Value

26. 54 28. 63 30. 72 32. 16 34. 25 36. 34 37 28 19 75 66 57

msec msec msec msec msec msec

29. 67 31. 11 33 20 35. 29

. . . .

Linearity

SID Determination 42. Distance from Base of Test Stand To Face of Vertical Cassette Holder

12
37. mR 38 40 If Change in mA Causes a kVp Shift, Readjust kVp Setting to Value Selected in Item 5 Above mR 45 39. 53 40. 58 41. 66 70 62 mR 57 mR 49 mR

.
41 44

cm

43. Distance from Face of Vertical Cassette Holder to Image Receptor

.
50 52

cm

38.

44. Outside Separation of Image of Focal Spot Strips

.
63 65

cm

X-Ray Field/Image Receptor Size Comparison (Fixed Collimation Only)

45. Image Receptor Horizontal Dimension 46. Image Receptor Vertical Dimension

.
11 17 13 19

inches inches

OR 14 OR 20

.
16 22

cm cm

47. X-Ray Field Image Horizontal Dimension

.
23 25

cm

48. X-Ray Field Image Vertical Dimension

cm 26 28

13
Actual Versus Indicated Field Size 49. Beam Limiting Device Numerically Indicates Field Size 29 50. Indicated Field Horizontal Dimension 51. Indicated Field Vertical Dimension 36 52. Light Field Horizontal Dimension cm 42 44 Y--YES N--NO

.
30 32

in in 38

OR 33 OR 39

.
35

cm cm 41

.

. .
45 47

53. Light Field Vertical Dimension

FORM FDA 3261 (2/83)

PAGE 2 OF 3 PAGES

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

FIELD TEST SERIAL NO. (1-8)

VERTICALLY MOUNTED CASSETTE HOLDER RADIOGRAPHIC SYSTEMS FIELD TEST RECORD
(Use Form FDA 2782, Field Test Record Continuation, if more space is needed.)
Illuminance 54.

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

VC
REGIONAL REVIEW (NAME)

13

total 56. total

ambient ambient

48 54

. .

55. fc 50 fc 56 total 57. total ambient ambient 51

.
53

fc fc 59

.
57

X-Ray Field/Light Field Alignment and Size Comparison 58. X-Ray Field Horizontal Dimension 60 60. Light Field Horizontal Dimension 66 62. Horizontal Misalignment

.
62

cm cm 68 cm 73

59. X-Ray Field Vertical Dimension 61. Light Field Vertical Dimension 63. Vertical Misalignment 74 63

.
65

cm

. .
72

.
69 71

cm cm 75

.

X-Ray Field/Image Receptor Centers Comparison 64. Centers Misalignment 11 Standby Radiation: (Capacitor discharge equipment only) 65. 66. X-Not Applicable 13 14

.
12

cm

14

.
18

67. mR 21 min 20 21 sec

REMARKS

FORM FDA 3261 (2/83)

PAGE 3 OF 3 PAGES