Image Gently Pledge


 

 

Yes, I want to image gently

Recognizing that every member of the healthcare team plays a vital role in caring for the patient and wants to provide the best care, I pledge:


First Name *

Last Name *

Email *

Profession/Role *
State of practice *
If other, please provide:
Name of primary institution/hospital *
Country of Practice
Primary Practice Type - Please check the description that most accurately reflects the location where you primarily practice
If other type, please provide:
How did you learn about the Image gently campaign?
If other, please provide
Do you wish to be contacted with updates on radiation safety?
Yes
No
The next 4 questions are for imaging professionals. Estimate pediatric % of practice
If you performed 100 CT scans today, how many would be for children?
Do you currently have different protocols for children and adults?
Yes
No
Do you routinely perform multi-phase, pre-contrast, post-contrast, delayed, exams in children?
Yes
No
Does your facility complete CT protocol forms for each patient?
Yes
No
The following questions pertain to Pediatric Interventional Radiology Practice. If you performed 100 IR procedures this week, how many would be for children?
Do you currently use different radiation techniques for IR procedures in children versus adults?
Yes
No
Do you routinely record radiation dose for each IR case?
Yes
No
Do you perform annual IR staff radiation safety education?
Yes
No
Does your IR team currently review radiation safety steps prior to each pediatric IR case?
Yes
No