Republic of the Philippines

Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION,
RADIATION HEALTH, AND RESEARCH

Form No.: QWP-CDRRHR-4-04-Annex 2.1

Revision: 01

RADIATION PROTECTION SURVEY AND EVALUATION (RPSE) CHECKLIST

(General Radiography Facility)
Name of Facility

Address

X-ray License No. Validity

1.0 PERSONNEL

1.1 The head of the x-ray facility who is the person-in-charge of the activities shall be the qualified physician as
defined in Administrative Order No. 35, s. 1994 of the Department of Health
Name PRC No.

1.2 A fulltime x-ray/radiologic technologist who is registered with the Professional Regulation
Commission (PRC) shall be hired for each machine.
Name PRC No.

1.3 The Radiation Protection Officer who is either the head of the facility, a medical physicist or a chief
radiologic or x-ray technologist with at least ten years working experience and attended a course on
radiation protection conducted by an organization recognized by the CDRRHR.
Name PRC No.

2.0 X-RAY MACHINE

2.1 The total filtration shall be indicated on the exterior source assembly at least 2.5 mm a1 equivalent.
2.2 A set of cones or fixed diaphragms, or an adjustable collimator with light beam indication shall be
provided. The cones or diaphragms shall be clearly marked with the following field sizes and distances: 14
x 17 at 72 inches, 10 x 12 at 72 inches, 14 x 17 and 8 x 10 at 36 inches.
2.3 A visible mark on the exterior source assembly indicating the location of the focal spot shall be provided.
2.4 The x-ray tube leakage shall be reduced to a value not greater than 1 mGy (100 mrad) in one hour at one
meter from the focus.
2.5 The control panel shall be provided with positive audible/or visible indication of the production of x-rays
whenever the tube is energized.
2.6 The control panel shall be provided with devices (labeled control dials, push buttons and/or meters) for
setting and/or indicating physical factors (such as kVp, mA, exposure time, or mAs) used for exposure.
2.7 The radiographic exposure switch of the dead-man or spring loaded type shall be provided.
2.8 A device that automatically terminates the radiographic exposure at the pre-set time interval or exposure at
the receptor shall be provided.

3.0 X-RAY EXAMINATION ROOM

3.1 X-ray room size shall satisfy the following specifications:

3.1.1 x-ray room not equipped with table shall have a room size of at least 2.5m x 3.0 m. For a
transportable facility the width of the room shall be at least 2.0 m.
3.1.2 x-ray room equipped with stationary patient table shall have a room size of at least 3.5m x 4.0m.
3.1.3 x-ray room equipped with tilting patient table shall have a room size of at least 4.5m x 4.5m
3.1.4 for specialized facilities, the size of the x-ray examination room should be in accordance with the
specification of the x-ray equipment manufacturer

_______________________________________________________________________________________________
Building 24, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Telefax Nos. (632)711-60-16, Trunk Line: (632)651-78-00 local 3401 to 05, 3408 to 12
URL: http://www.doh.gov.ph; e-mail: apperalta@co.doh.gov.ph
 3.2 Door leading to the x-ray room must be lined with at least 1.5 mm (1/6 inch) thick lead sheet to a height of
at least 2 meters from the floor/ground outside.
3.3 The base of the examination room window/s shall be elevated to a height of at least 2 meters from the
floor/ground outside the x-ray examination.
3.4 A red warning light bulb that is automatically illuminated when the x-ray machine is switched on shall be
installed outside the x-ray examination room above the x-ray room door.
3.5 A warning notice shall be put outside the x-ray examination room door. It shall be made up of a solid
yellow equilateral triangle 180mm long on each side. At the center of the triangle is a black tre-foil sign
for radiation. Under the triangle are the words “X-RAY ROOM: DO NOT ENTER WHEN THE RED
LIGHT IS ON”. The warning notice shall be on a a 180 mm x 270 mm white background.
3.6 Adequate ventilation shall be provided inside the x-ray examination room.
3.7 The room shall be provided with adequate shielding from scattered and transmitted x-rays.

4.0 DARKROOM

4.1 Light leaks into the darkroom shall be corrected.

4.2 A light tight air outlet with an exhaust fan should be installed inside the darkroom.
4.3 For manual processing, processing tanks consisting of master tank two (2) insert tanks made of stainless
steel or fiber glass shall be provided.
4.4 Separate paddles for the developer and fixer solutions shall be provided.
4.5 There should be an adequate supply of fresh water.
4.6 A luminous interval timer/digital timer shall be provided.
4.7 A darkroom thermometer or digital thermometer or alcohol thermometer shall be provided
4.8 A standard safelight with 10-15 watt light bulb shall be provided.
4.9 The safelight housing shall be provided with a safelight filter made of glass or hard plastic, tinted with
amber or red and which does not fog a pre-exposed film within 45 seconds.
4.10 The safelight housing shall be installed not lower than 4 feet from the working table and the processing
tanks.
4.11 Unprocessed films shall be properly shielded in a cool dry place protected from x-rays. Films shall be
stored vertically on its end. This prevents marks on film because of pressure due to its weight.
4.12 Intensifying screens shall be kept clean or replaced when necessary.

5.0 ACCESSORIES

5.1 A set of contact gonad shields with a minimum lead equivalence of 1.5 mm lead shall be provided.
5.2 An upright gonadal shield for chest examination with a minimum lead equivalence of 1.5 mm lead shall be
provided.
5.3 A lead rubber apron, with lead equivalence of 0.25 mm shall be provided.
5.4 A pair of lead rubber gloves/lead hand protector with lead equivalence of at least 0.25 mm shall be
provided.
5.5 A caliper to measure the thickness of the patient shall be provided.
5.6 A fixed/movable protective barrier to a height of at least 2 m from the floor shall be provided. For a fixed
protective barrier it shall be made of 15.25cm (6 inches) poured concrete or 1.50mm thick lead sheets. For
a movable protective barrier it shall be made of 1.50mm thick lead sheets.
5.6.1 The fixed/movable protective barrier shall be covered with a lead glass/acrylic viewing window
with lead equivalence of at least 1.5 mm.
5.6.2 If the fixed/movable protective barrier in item 5.6 has no opening for a lead glass/acrylic
viewing window then a mirror large enough and positioned in such a way that the operator can
see the patient during the x-ray examination shall be provided.

6.0 ADMINISTRATIVE REQUIREMENTS

6.1 The owner/licensee shall ensure that the facility complies with the above requirements.
6.2 The owner/licensee shall provide personal dose monitor (TLD or OSL) to all radiation workers in the
facility.
6.3 The head of the facility shall establish quality control program for the x-ray facility in accordance with the
CDRRHR protocol on quality control. He shall ensure that no unlicensed person operates the x-ray
equipment.
6.4 The Radiation Protection Officer shall be responsible for the conduct of radiation safety program in the
facility. He/she shall keep record of occupational radiation doses received by the radiation workers in the
facility. He/she shall ensure that no worker shall exceed the dose limit of 20 mSv per year averaged over a
period of five (5) years.
7.0 OTHER IRREGULARITIES

7.1 Cleanliness and orderliness of the whole x-ray facility shall be observed.
7.2 The following charts and tables, technical manuals, and records shall be made available to the CDRRHR
health physics team during the conduct of radiation protection survey and evaluation.
7.2.1 Radiographic technique charts per x-ray machine shall be provided.
7.2.2 X-ray tube rating and anode cooling charts must be kept.
7.2.3 Operation manuals and circuit diagrams must be kept.
7.2.4 Time-temperature chart shall be provided.
7.2.5 Records of maintenance and repair jobs of x-ray machine including mechanical and electrical
safety programs must be kept.
7.2.6 Records of film spoilage/rejects must be kept.
7.2.7 Records of preventive maintenance of automatic processors and accessories must be kept.
7.2.8 Records of frequency of changing solutions or replenishment must be kept.
7.2.9 Files of written results signed by the qualified physician as defined in A.O. 35, s.1994 of the
Department of Health must be kept.
7.2.10 Records of x-ray examinations performed with the corresponding written request must be kept.

8.0 GENERAL RECOMMENDATIONS

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Immediate processing of your license to operate an x-ray facility will be based upon your submission of
the following documents:

1. duly accomplished x-ray license application form

2. Notarized certificate of employment of radiologist and x-ray/radiologic technologist
3 Certification of training of doctor if he/she is not a fellow/diplomate of the Philippine College/Board of
Radiology (PCR)
4 Photocopy of the PCR certificate of the radiologist (if diplomate or fellow)
5 Photocopy of PRC license and certificate of the radiologist and x-ray/radiologic technologist
6. Certificate of training in radiation protection of the radiologic/x-ray technologist if he/she acts as
Radiation Protection Officer
7. notarized certificate of compliance
8. proof of compliance (pictures, receipts, logbooks, charts, etc.) with the above deficiencies
9. license application fee in the form of postal money order payable to the Food and Drug Administration
with address at Alabang, Muntinlupa City
10. copy of business/mayor’s permit

CDRRHR health physics team that conducted the radiation protection survey and evaluation:
Name & Position Date

Name & Position

A copy of this report was received by: Name & Position