Shielding Design Specs Request Form

Shielding Design Specs Request Form

Please follow directions below to ensure timely response to your shielding design request.

1. Please fill out the shielding design spec form below completely. Any missing information will slow down the completion of the shielding design. Note: we must have the legal name AND physical address for the facility.

2. Attach the following Scale drawings (i.e. scale-1/4"=1 foot). Some states will not accept a design without a scale indicator.

a. Room in which the unit will be placed

i. This drawing must have position of radiation equipment, operator barrier, and wall bucky, if applicable labeled as well

b. Floor on which the unit is located

i. This drawing must have all surrounding areas on the drawing labeled (e.g. storage closet, corridor, office space, hallway, exterior, bathroom, etc.)

c. Any occupied spaces above and/or below the unit

i. This drawing must have the all areas above/below the room in which the unit will be placed highlighted/circled and labeled (e.g. storage closet, corridor, office pace, hallway, exterior, bathroom, etc.)

Please complete this form. Your drawing(s) may be attached to this form using the upload area at the bottom, faxed to (770) 645-1441, or emailed to: portal@ptcphysics.com Please note that dimensions of a radiographic room must be 8' x 10' or greater.

Shielding Design Specifications:

Shielding Design Specifications

Physical Address of Unit Location

Mailing Address for Shielding Design

Billing Address

Room / Equipment Information

Composition of Building
Material Between Floors:*(e.g.concrete slab,membrance
roof over insulation,etc.)

Thickness of Building
Material
Between Floors:*

If Material Between Floors
is Concrete, is it:*

CT Rooms ONLY:*
(should total 100% when
added together)

Head Scans
Head Scans
Body Scans
Body Scans

C-Arm Rooms
ONLY:

Does Attached Drawing of Room have each Surrounding area labeled?

.

Sending

Please Fax Or Email all floor plans and additional attachments to our office.
Fax: (770) 645-1441
Email: Portal@ptcphysics.com
Shielding Design Fees: $575.00/room; S PECT, PET, and PET/CT Suites $650.00/room. Integrity Fees: $775/room.

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