Shield Design Form

General Information

Applicant/Primary Contact

Shielding Design

Number of Rooms

Room Information

Rad

Fluoro

Dental

Rad Mobile

Fluoro Mobile

Dental Mobile

CT

Mammo

Nuclear Medicine

Industrial

Other

File Upload

You must include:

▪ Accurate scale

▪ All adjacent spaces to room labeled, including above and below

▪ Position of all X-ray equipment shown in room layout

▪ Control booth shown if appliciable

▪ Include any known materials and amounts for the contsruction of the walls, floor, ceiling, doors and windows

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Shield Integrity

Physics Survey

Type
Number of Units
Is New
Rad
Fluoro
Dental
CT
Mammo
Nuclear Medicine
Industrial
Other

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