Pediatric Radiation Safety Survey Form
Please complete the Pediatric Radiation Safety Survey Form to help us assess current pediatric radiation safety practices.
What is your primary role in the facility?
*
Radiologist
Technologist
Physicist
Nurse
Administrator
Other
How frequently are pediatric radiation safety protocols reviewed at your facility?
*
Monthly
Quarterly
Annually
Rarely
Never
Please rate your agreement with the following statements regarding pediatric radiation safety:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Protocols are clearly defined
1
2
3
4
5
Staff receive regular training
6
7
8
9
10
Equipment is routinely checked
11
12
13
14
15
Dose monitoring is standard practice
16
17
18
19
20
How confident are you in identifying when pediatric radiation exposure is unnecessary?
*
1
2
3
4
5
How often are dose reduction techniques used during pediatric imaging?
*
Always
Often
Sometimes
Rarely
Never
Indicate the frequency of the following pediatric radiation safety activities:
*
Rows
Always
Often
Sometimes
Rarely
Never
Patient shielding is applied
21
22
23
24
25
Equipment calibration is performed
26
27
28
29
30
Radiation dose is documented
31
32
33
34
35
Procedures are explained to caregivers
36
37
38
39
40
How would you rate the effectiveness of communication with caregivers regarding radiation risks?
*
1
2
3
4
5
Which of the following best describes your facility's approach to pediatric imaging protocols?
*
Standardized protocols for all ages
Separate pediatric protocols
Protocols adapted case by case
No formal protocols
How satisfied are you with the current pediatric radiation safety measures at your facility?
*
1
2
3
4
5
Please provide any additional comments or suggestions regarding pediatric radiation safety at your facility.
Submit Survey
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