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CT EQUIPMENT QUALITY CONTROL DATA FORM

Facility Name:
Month: Year: CT Scanner:
Day WU AC Mode CTwater (HU) Noise (SD) Artifacts P/F Initials Monthly Visual Checklist
1 Axial Table height indicator………………….
2 Helical Table position indicator………….…………………
3 Axial Angulation indicator…………………………………
4 Helical GANTRY Laser localization light………………………………
5 Axial High voltage cable/other cables……………………
6 Helical Smoothness of table motion…….…………………
7 Axial X-Ray on indicator………………..…………………
8 Helical Exposure switch………………….…………………
9 Axial Display window width/level…………………………
10 Helical Panel switches/lights/meters………………….
CONTROL
11 Axial CONSOLE X-Ray on indicator………………….………………
12 Helical Door interlocks………………….………………….
13 Axial Warning labels………………….………………….
14 Helical Intercom system………………….…………………
15 Axial Postings………………….………………….
16 Helical Service records………………….…………………
OTHER
17 Axial
18 Helical
19 Axial Monthly Display Monitor
20 Helical 0%-5% contrast is discernible………………….
21 Axial 95%-100% contrast is discernible…………………
22 Helical Distinct gray level steps………………….
SMPTE
23 Axial PATTERN Alphanumerics discernible………………….
24 Helical High contrast patterns visible………………….
25 Axial Low contrast patterns visible………………….
26 Helical No artifacts………………….………………….
27 Axial Window: Level:
28 Helical Monthly Large Artifact Check
29 Axial If available, scan manufacturer's large phantom
30 Helical Artifacts:
31 Axial Date of Monthly QA: Initials:
Action Limits: CTwater = 0 ± 5 HU Noise: A ≤ H≤ PASS = P or  FAIL = F NOT APPLICABLE = NA
Comments/Corrective Action A = Axial H = Helical
WU = Warm Up (Daily)
AC = Air Calibration (Per Manufacturer Recommendation)

Qualified Medical Physicist Reviewer Date of Review