Table 3.

Survey questionnaire for IAEA Smart Card/SmartRadTrack Project, Form 3. Questions for Country with Current Tracking Program.

1. What type of program(s) to track medical radiation exposures/doses exist for your country? (Please select all that apply) ☐International ☐National ☐Regional within a country ☐Institutional/organizational, e.g. major hospitals

2. How widely are the program(s) to track medical radiation procedures and/or doses to your population implemented? (Please complete (a), (b), and (c) below.) Estimated population of country: Estimated % of population covered in health care system(s): Estimated % of population in (b) above where program exists:

3. Do 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 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 ☐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) are 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)

8. Which of the following is tracked for an individual patient? Please select all that apply. ☐Numbers of exams/procedures ☐Type of examination/procedure (e.g. CT) ☐Anatomic region/organ scanned (e.g. abdomen or heart) ☐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. How useful is the program? ☐Extremely useful ☐Very useful ☐Moderately useful ☐Mildly useful ☐Not useful ☐Not yet evaluated

10. For what purposes are collected data used? Please select all applicable. ☐Data is not yet used ☐Quality assurance, quality improvement ☐Policy development ☐Decision support for ordering exams, etc. ☐Reimbursement ☐Licensure/certification/regulation ☐Other (please specify):

11. What quantities are 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 ☐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 ☐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 ☐Other (please specify:

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

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

List additional measurements and associated modalities here:

12. Please describe your current program(s) to track cumulative medical radiation doses, including data collection and storage strategies, organization, number and types of participating sites, budget, etc.:

In addition, please attach a data collection form, if available.