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Appendix D INSPECTION REPORT (ORC-R11) FOR OFFICIAL USE ONLY Page 1 of 2 Registration # Date of Inspection: Facility Name Address City, State, ZIP Phone Exp. Date / / Specify Facility Type DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Office of Radiation Control (302) 744-4546 Total # of x-ray tubes at this location Number of Violations (see comments) #Tubes Inspected Violation Severity Level I II (circle) Hospital Medical Dental Veterinary Podiatric Chiropractic Industrial Other N/A A. Total Number Users C. # Certified Radiation Techs: D. Employees Monitored: Y GENERAL ADMINISTRATIVE ITEMS B. Total Number Occupationally Exposed Lic. Prac. Dental Hyg Others N E. Total Number Monitored G. Monitoring System Adequate: Y N 5000 mR/Year: WB 15000 mR/year: Ext F. Monitoring Records Satisfactory: Y H. Number over : WB 1250 mR/Quarter: WB N Ext 3750 mR/Quarter: Ext I. Number Patients Radiographed (Avg./week) K. Number Patients Fluoroscoped (Avg./week) L. Number Therapy Treatments (Avg./week) M. Number Nuclear Medicine Administrations (Avg./Week) N. Brand/Type X-ray Film Used O. Type of Intensifying Screen J. Patient Work load (#/year) :_______ (avg./week X 4weeks X 12months) P. Digital Y N ___________________________________________________________ Q. Radioactive Material Present: Y N S. Current State Registration Posted: Y N U. Written Safety Procedures: Y N W. ORC-R1 data current: Y N X.ReasonforInspection: Regular Follow-Up ORC-R11/Facility (05/14) R. Registered By: DE Licensed By: NRC T. Notice to Employees Posted: Y N V. Records/Corr./Copy of DRCR: Y N Investigation Complaint Other 12PDF Image | Radiation Machine Registration Permit Manual
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