Table 2.

Survey questionnaire for IAEA Smart Card/SmartRadTrack Project, Form 2. Questions for Country Planning a Radiation Tracking Program.

1. When do you plan to establish a program to track medical radiation exposures/doses? ☐Within the next 2 years ☐2 to 5 years ☐Beyond 5 years ☐Time frame is uncertain

2. What type of program is it? ☐International ☐National ☐Regional within a country ☐Institutional/organizational e.g. major hospitals

3. Will the program(s) track examinations for an individual patient? (e.g. multiple CT scans to the same patient) ☐Yes ☐No ☐Don’t know

4. What are the goals of your planned program(s) to track medical radiation exposures/doses (please select all that apply)? ☐Quality assurance/quality improvement ☐Policy development ☐Decision support for ordering exams, etc ☐Reimbursement ☐Licensure/certification/regulation ☐Uncertain ☐Other (please specify):

5. How do you plan to record data in this program? ☐On paper ☐By computer with methodology to help individual person track ☐By computer with methodology to help health authorities track

6. Will data collected be transmitted to a centralized database? ☐Yes ☐No

7. Which types of examinations (modalities) will be tracked? Please select all that apply. ☐Conventional radiography/x-ray ☐Computed radiography (CR) ☐Digital radiography (DR) ☐Dental radiography ☐Mammography ☐Fluoroscopy, Diagnostic ☐Fluoroscopy, Interventional ☐Computed Tomography (CT) ☐Nuclear Medicine (Planar) ☐Nuclear Medicine (SPECT) ☐Nuclear Medicine (PET) ☐Nuclear Medicine (Hybrid with CT) ☐Uncertain

8. Which of the following will be tracked for an individual patient? Please select all that apply. ☐Numbers of Exams/Procedures ☐Type of examination/Procedure (e.g. CT) ☐Radiation dosimetric information (e.g. Dose-Length Product, in mGy x cm) ☐Geographic information about Exam/Procedure (e.g. in Northern Province) ☐Information about specific site performing Exam/Procedure (e.g. at National University Hospital) ☐Uncertain ☐Other (please specify):

9. Once collected, for what purposes will the data be used? Please select all applicable. ☐Quality assurance, quality improvement ☐Policy development ☐Decision support for ordering exams, etc. ☐Reimbursement ☐Licensure/certification/regulation ☐Uncertain ☐Other (please specify):

10. What quantities will be tracked for? Please select all applicable.

Projection radiography (x-ray, computed/digital/dental radiography) ☐Entrance surface air kerma ☐Dose-Area Product (DAP)/Kerma-area product (KAP) ☐Exposure index ☐Organ Absorbed Dose(s) ☐Effective Dose ☐Uncertain ☐Other (please specify):

Fluoroscopy ☐Fluoroscopy time ☐Fluoroscopy runs ☐Cine time ☐Cine runs ☐Dose-Area Product (DAP)/Kerma-area product (KAP) ☐Dose/Air kerma at the interventional reference point (cumulative) ☐Peak/Maximum Skin Dose ☐Organ Absorbed Dose(s) ☐Effective Dose ☐Uncertain ☐Other (please specify):

Computed Tomography ☐CT Dose Index, weighted (CTDIw) ☐CT Dose Index, volume (CTDIvol) ☐Dose-Length Product (DLP) ☐Organ Absorbed Dose(s) ☐Effective Dose ☐Uncertain ☐Other (please specify):

Mammography ☐Incident entrance air kerma ☐Average Glandular Dose ☐Exposure index ☐Uncertain ☐Other (please specify):

Nuclear Medicine ☐Administered Activity (MBq) ☐Organ Absorbed Dose(s) ☐Effective Dose ☐Uncertain ☐Other (please specify):

List additional measurements and associated modalities here: