Shielding

Installation type:

Reason for requesting shielding assessment:

Potential visit date

Date of work / changes:

Date of work/changes:

Start date

End date

To carry out the shielding assessment, it is essential to include the following elements with your request:

Number of rooms to be evaluated (with X-ray machine)?

* For each room, specify:

The type of room (Hygienist, dentist, mammo, chiropractor, etc.)
The type of occupation
The type of devices (note: please include brand and model if possible)
The expected weekly workload for each room with an X-ray machine (i.e. the maximum number of X-ray images taken each week, per room and device)
(Note: for several rooms using the same device model with the same workload, you may group the information in the room number, ex: room 101, 102, 103)

Room 1:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 2:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 3:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 4:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 5:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 6:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 7:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 8:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 9:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 10:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 11:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 12:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 13:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 14:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 15:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 16:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 17:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 18:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 19:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

Room 20:

Type of room:

Type of upstairs occupation:

Main composition of the ceiling:

Type of downstairs occupation:

Main composition of the floor:

Room number:
(As written on the submitted plan)

Type of device:

Number of shots/week (intra or general X-ray device):

Number of shots/week (Pan 2D):

Number of shots/wk (CBCT 3D):

Number of shots/week (CEPH):

*Plan required to perform the shielding assessment:

The scale plan should include the following information:

Description of adjacent rooms (examples: reception, hygienist room, operating room, office, toilet, corridor, etc.);
The type of device installed
The location of x-ray machines and patient chairs in the room (s);
The location of the X-ray activation buttons
The presence of doors and / or windows, if applicable;
When some walls face another business, indicate what is in the room adjacent to that wall;
The current or planned content of the walls, where possible.

*Attach the scale plan of the facilities to this request (preferably a PDF format):

File upload

Maximum file size: 5MB

Important information:

A shielding assessment is required for any new installation, for a move, renovation, replacement or addition of device as well as an increase in workload.

Subsequently, on-site verification of shielding and equipment is also required prior to clinical use. One of our physicists can perform this check, you will only have to make an appointment.

Our normal business hours are 8:00 a.m. to 5:00 p.m.

Your request will be processed in the next working days.

Location of the site targeted by the shielding calculation

Name of the institution:

Address:

City:

Postal code:

Administrative region:

Name of the contact person:

E-mail address:

E-mail addresses to send copies to (to include project managers or architects etc.):

To enter multiple e-mail addresses, separate them with commas.
Ex: [email protected],[email protected]

Phone number:

Billing address

Same address as the one targeted by the shielding calculation

Billing address

Address:

City:

Postal code:

Administrative region:

Name of the contact person:

E-mail address:

Phone number:

Service call

Shielding call

Shielding service call

Date of work / changes:

Room 1:

Room 2:

Room 3:

Room 4:

Room 5:

Room 6:

Room 7:

Room 8:

Room 9:

Room 10:

Room 11:

Room 12:

Room 13:

Room 14:

Room 15:

Room 16:

Room 17:

Room 18:

Room 19:

Room 20:

Location of the site targeted by the shielding calculation

Billing address

Billing address