X-Ray Screening Checklist Form
Complete this checklist to ensure all required steps of the x-ray screening process are followed. This form is for task tracking only and does not collect sensitive health information.
Screening Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Screening Location
*
Operator Name
*
Equipment Inspection Completed
*
Yes
No
Protective Gear Provided to All Present
*
Yes
No
Warning Signs Displayed
*
Yes
No
Patient Identification Confirmed
*
Yes
No
Correct Procedure Verified
*
Yes
No
Exposure Settings Checked
*
Yes
No
Additional Comments
Submit Checklist
Should be Empty: