Chapter 3
APPENDIX I


SAMPLE QUESTIONNAIRE FOR RECORDING DATA ON EQUIPMENT, RADIOGRAPHIC TECHNIQUE AND DOSE








QUESTIONNAIRE

Type of examination:____________________________



A) RADIOGRAPHIC TECHNIQUE » to be filled in by the radiographer/radiologist

A.1. CT scanner  
 
  • Manufacturer/Type: ............................../..............................
  
 
  • Year of manufacture: ..............................
  
A.2. Patient position  
 
  • Supine
 
  • Prone
 
  • Other position, describe: ............................................................
  
A.3. Gantry tilt  
 
  • None
 
  • Cranial, degree
 
  • Caudal, degree
A.4. Hard copy facilities  
 
  • Laser camera
 Manufacturer/Type: ............................../..............................
  In use since (date): ............................................................
 
  • Film
 Manufacturer/Type: ............................../..............................
 
  • Film Processor
 Manufacturer/Type: ............................../..............................
  Processing Time: sec.
  Developer Temperature: °C



B) PATIENT RELATED DATA » to be filled in by the radiographer/radiologist

B.1. Age: years
B.2. Sex: F M
B.3. Height: cm
B.4. Weight: kg



C) IMAGE VIEWING DATA » to be filled in by the radiographer/radiologist

Settings Sequence 1 Sequence 2 Sequence 3
C1) Reconstruction algorithm    
C2) Field of view    
C3) Window width    
C4) Window level    



D) DOSE RELATED DATA

D.I) DOSE RELATED DATA » to be filled in by the radiographer/radiologist

Details of technique Sequence 1 Sequence 2 Sequence 3
Exposure factors

   Tube voltage (kV)

   Tube current x exposure time (mAs/slice) (1)

   Tube current x total acquisition time (mAs total) (2) 		 


  
   
   
Slice thickness (mm)    
Couch increment (table feed) (mm)    
Number of slices    

(1)For serial scanning;
(2)For helical scanning



D.II) DOSE RELATED DATA » to be filled in by the physicist

Quantity Sequence 1 Sequence 2 Sequence 3
Tube filtration setting (3)    
nCTDIw (mGy/mAs) (4)    
CTDIw (mGy) (5)    
Dose-length product (mGy x cm)    
Total dose-length product (mGy x cm) (6)  
Phantom diameter (cm)  

(3)List of this can be varied
(4)

The normalized weighted CT dose index nCTDIw has to be determined for the radiation quality (tube voltage, filtration) and beam geometry (focus to axis distance, FOV, beam shaping) as used in the respective sequence;

(5)Per slice for serial scanning and per rotation for helical scanning
(6)Sum of all sequences