Shielding Calculation Request Form

Bone Density Patient Workload

Please Use Maximum Projected Workload Figures.

Exams Per Week	Scan Time (sec)

CATH Lab Patient Workload

Please Use Maximum Projected Workload Figures.

Number of Exams Per Week
Number of Cine or Digital Runs Per Exam
Length of Each Cine or Digital Run (seconds)
Average Cine or Digital Pulse Sequence (FPS)
Average Cine or Digital Pulse Width (seconds)
Length of Fluoroscopic Exam (minutes)
Percentage of Workload Done with Lateral X-Ray Beam
Direction of Lateral X-Ray Beam

CT Patient Workload

Please Use Maximum Projected Workload Figures.

Procedure	Exams Per Week	kVp	mA	Rotation Time (sec)
Brain Exams
Chest Exams
Abd/Pelvis Exams
Other Exams

Dental Patient Workload

Please Use Maximum Projected Workload Figures.

Exams Per Week	Exposures Per Exam	Ave. mAs/Exp.

Fluroscopic Patient Workload

Please Use Maximum Projected Workload Figures.

Exams Per Week	Time Per Exam

Industrial Radiography Workload

Due to the unique conditions of this type of shielding our team will reach out to you to discuss your facilities specific shielding needs.

Please continue with completing the form to submit your request.

MAMMO Patient Workload

Please Use Maximum Projected Workload Figures.

Exams Per Week	Exposures Per Exam	Ave. mAs/Exp.

SPECT Patient Workload

Please Use Maximum Projected Workload Figures.

Radioactive Material Used
Administered Dose (mCi)
Average Scan Time

CT Patient Workload (If Applicable)

Please Use Maximum Projected Workload Figures.

Procedure	Exams Per Week	kVp	mA	Rotation Time (sec)
Brain Exams
Chest Exams

CT Patient Workload

Please Use Maximum Projected Workload Figures.

Procedure	Axial or Sprial Scan Type	Exams Per Week	kVp	mA	Rotation Time (sec)
Brain Exams
Chest Exams
Abd/Pelvis Exams
Other Exams

PET Patient Workload

Please Use Maximum Projected Workload Figures.

Radioactive Material Used
Administered Dose (mCi)
Number of Procedures Per Day
Length of Time Patient is in Holding Room Prescan (mins)
Length of Time Patient is in Imaging Room (mins)

Podiatry X-Ray Beam Geometry

Please Use Maximum Projected Workload Figures.

Percentage of exposures with lateral X-ray beam
Lateral X-Ray Beam Direction

Podiatry Patient Workload

Please Use Maximum Projected Workload Figures.

Exams Per Week	Exposures Per Exam	Ave. mAs/Exp.

Radiographic Patient Workload

Please Use Maximum Projected Workload Figures.

Procedure	Exams Per Week	Exposures Per Exam	Average mAs/Exp.
Table Exams
Chest Exams
Lateral Exams

Radiographic Patient Workload

Please Use Maximum Projected Workload Figures.

Procedure	Exams Per Week	Exposures Per Exam	Average mAs/Exp.
Table Exams
Chest Exams
Lateral Exams

Fluoroscopic Patient Workload

Please Use Maximum Projected Workload Figures.

Exams Per Week	Time Per Exam

Veterinary Patient Workload

Please Use Maximum Projected Workload Figures.

Radiographic	Exams Per Week	Exposures Per Exam	Ave. mAs/Exp.
Table Exams