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* 3. Location/Department where examination was performed:

* 5. Accession # or other Identification number that does not violate HIPPA

* 6. What was your involvement for this specific examination?

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Observed
Hands on
Performed Independently (Indirect/Direct supervision)

* 7. N/A

* 8. Did you repeat a specific examination? If the answer is yes, please answer the next question.

* 9. Please provide the following patient information for REPEAT EXAMINATIONS ONLY:

* 10. Reason for Repeat

  Inaccurate kilovoltage (kVp) calibration Inaccurate milliamperage (mA) calibration Inaccurate timer calibration Inaccurate automatic exposure control (AEC) response Dirty or damaged cassettes Improperly labeled or damaged grids Malfunctioning collimators Improper film storage Incorrect or inconsistent film processing Use of incorrect technical factors (kilovoltage, millamperage, distance, time) Incorrect positioning Failure to measure the patient with caliper Improper collimation Improper use of accessories such as grids, cassettes Improper handling of unexposed or exposed film Failure to communicate clearly to the patient to hold the breath or to hold still
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2
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5

* 11. N/A

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