DUBAI HEALTH AUTHORITY

Medical Physics Section

Radiation Safety Assessment Request

For Authorization and Inspection of X-Ray Facilities
‫طلب تقييم السالمة االشعاعية لترخيص استخدام االشعة السينية في المنشآت الطبية‬
Assessment No/ ‫ رقم الطلب‬/ RAD MP / . …….…………

FACILITY DETAIL ‫بيانات المنشأة‬

Facility Name ‫اسم المنشأة‬

Facility Owner ‫مالك المنشأة‬

Facility Manager ‫مدير المنشأة‬

Facility RPO ‫مسؤول الوقاية من االشعاع‬

Trade License ‫رقم الترخيص التجاري والهيئة‬

‫االتحادية للرقابة النووية‬
and FANR no.

Facility Location ‫موقع المنشأة‬

– ‫الهاتف – الفاكس‬
Phone:………………………… Mob:……………………………. ‫البريد االلكتروني‬
Telephone/ Fax/
E-mail
Fax:…………………………. E-mail:

□ Hospital / Diagnostic Center □ Polyclinic / Specialty Clinic ‫نوع المنشأة‬

Facility Type
□ Others (Specify)……………………………………………………………..

Services provided ‫الخدمات المقدمة‬

□ Gen. Radiology ( Fixed / Mobile )

□ Fluoroscopy ( Fixed / Mobile )

□ Mammography ( Fixed / Mobile )

□ Conventional Dental ( Fixed / Mobile)
□ Chiropractic Radiography

□ Bone Mineral Densitometry

□ Computed Tomography
□ Others (Specify)……………………………………………………………..

1
Laila Al Balooshi, Head of Medical Physics Section, Dubai Hospital, P.O. Box 7272, Dubai, UAE
Tel: +9714 2196140, Email Lgalbalooshi@dha.gov.ae
 DOCUMENTATION FOR RADIATION PROTECTION REQUIREMENTS ‫الوثائق المطلوبة لبرنامج الحماية من االشعاع‬
1 List of Occupational Personnel ‫قائمة موظفي االشعة‬
Degree completed / no. of Years of Experience
Full Name of the Staff Position in radiology Licensed by
Certification in Radiology
‫اسم الموظف المعني‬ ‫الوظيفة‬ ‫جهة الترخيص‬
‫المؤهالت العلمية‬ ‫سنوات الخبرة‬
1 RPO

2
3

Radiation Protection Program - Provide a radiation safety Local Rules and the relevant radiation protection
2 ‫برنامج الوقاية من االشعاع‬ procedures

- Provide the name and function of the person (doctor, physicist or radiographer)
Radiation Protection Officer
designated as responsible for radiation protection matters
3 ‫مسؤول الوقاية من االشعاع‬
- Provide training, experience.
- Attach drawings, layout of the facility, and other information as applicable as
List of Facilities and Equipment following:
4 ‫قائمة المنشآت واالجهزة‬ o Composition and thickness of the walls
o X-ray room dimensions
o all doors and windows on the drawing
o The position of the operator and the X-ray control panel
o Direction of the beam
o Occupation of the adjacent spaces behind each wall
o Radiation Shielding : Required Data for the radiation shielding thickness
X-Ray
Type of Installed Max. Max. Weekly Wall Lead
Manufacturer Model # Room
X-ray Equipment on Voltage Current Workload Thickness
Dimensions
1
2
3

Protective Clothing or Accessories

5 - Provide protective coats, gloves, caps, eye glasses..etc to occupational personal
‫ادوات التدريع والحماية‬
Tools and Equipment Number Shield thickness Other Descriptions / Remarks (Manufacture, Location, …)

Radiological Emergency Plan

6 ‫اجراءات الطوارئ االشعاعية‬ - Submit a radiological emergency plan
Program to ensure Control of Radiation
7 sources - Attach required Quality Control reports for Radiation Protection Checking
)‫برنامج ضمان ظبط المصادر (االجهزة‬
Personnel Dosimetry - Provide the Personnel external monitoring (personnel dosimetry)
‫قياس الجرعات االشعاعية للموظفين‬
- Provide details on internal dosimetry (if applicable(

- Name of the company performing the monitoring ,Type of dosimetry badges, and Frequency
of the monitoring

2
Laila Al Balooshi, Head of Medical Physics Section, Dubai Hospital, P.O. Box 7272, Dubai, UAE
Tel: +9714 2196140, Email Lgalbalooshi@dha.gov.ae
 ‫ابعاد غرف االشعة والتدريع‬
MINIMUM DENTAL ROOM SURFACES AND SHIELDING THICKNESSES
‫المطلوب‬
Minimum
Main X-Ray Structural Shielding Minimum Shielding
Required Surface Remarks
Applications Material Walls & Thickness
Doors and Height

Conventional Leaded Doors and Walls: 2 mm

1 15 m2 Doors: 2 mm ------
radiography Walls
Height: 2 m
Combined Leaded Doors and Walls: 2 mm
2 Radiography and 20 m2 Doors: 2 mm -----
Walls
Fluoroscopy Height: 2 m
3 24 m2 Walls: 2 mm
Computed Leaded Doors and Please note that the
Tomography (CT) (Length: 6 m Walls Doors: 2 mm height of the shielding is
Width: 4 m) Height: from floor to ceiling from floor to ceiling!
4 Walls: normal stone wall
Walls: Stone Wall Board
(2.5 cm min)
9 m2 Doors: hard wood or Lead is Not
Mammography (3mX3m) steel Required in
Doors: 1 mm Steel or 2.5
Mammography
cm of hard wood
5 Walls: Stone Wall Board
Dental 2mX3m Doors: normal door 2.5 cm stone wall No door shielding is needed
6 Walls: normal stone
wall (2.5 cm ) 1 mm 2 mm lead window
Panoramic and Walls: Stone Wall Board
2mX3m Lead if any occupied with 2 mm leaded
Cephalometric
room is adjacent to door
the dental room
7
Walls: Stone Wall Board Operator must be at
Bone Densitometry 2mX3m Normal wall and door least 1.5 m from the
machine
8 One wall or two may not
Walls: Lead Doors: Walls: 1 mm lead
Chiropractic X-rays 15 m2 Lead Door: 1 mm Lead
need lead; this depends on
the position of the machine
and the Bucky.

3
Laila Al Balooshi, Head of Medical Physics Section, Dubai Hospital, P.O. Box 7272, Dubai, UAE
Tel: +9714 2196140, Email Lgalbalooshi@dha.gov.ae