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Wufoo

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:
• to make the image gently message a priority in staff communications this year
• to review the protocol recommendations and, where necessary, implement adjustments to our processes
• to respect and listen to suggestions from every member of the imaging team on ways to ensure changes are made
• to communicate openly with parents Thank you for committing to the goal to image gently when you image or treat children.
Spread the word in your department, practice, hospital or clinic
Name * First Last
Email *
Profession/Role *
General Radiologist Technologist Pediatric Radiologist Dentist Dental Hygienist Dental Assistant Pediatrician Nurse Physicist Hospital/Dept. Administrator Parent Family Practitioner Internist Physician Assistant General Interventional Radiologist Medical Student Dental Student Pediatric Interventional Radiologist Neuroradiologist or Interventional Neuroradiologist Other
If Other Profession/Role, please define:
Name of primary institution/hospital *
State of Practice *
Country of Practice *
Primary Practice Type - Please check the description that most accurately reflects the location where you primarily practice

Academic/University-based (e.g. Houston Medical School) Private Office/Imaging Center (e.g. Fairfax Radiology) Children's Hospital (e.g. Children's Memorial - Chicago) Community Hospital-based (e.g. Reston Hospital Medical Center) Multi-Specialty Clinic (e.g. Mayo Clinic) VA/Military/Public Health System (e.g. Maxwell Air force Base RAD) HMO (e.g. Kaiser Permanente System) Other
If Other, please define:
How did you learn about the Image Gently Campaign?
AADMRT AAOMR AAP AAPD AAPM ACR ADA AOCR ARRS ARRT ASRT AUR CRCPD NCRP RSNA SCBT-MR SPR Press Trade Publication Scientific Publication Google SIR State of Minnesota website
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:
0 - 10% 11 - 20% 21 - 30% 31 - 40% 41 - 50% 51 - 60% 61 - 70% 71 - 80% 81 - 90% 91 - 100%
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
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Wufoo

The next 4 questions are for imaging professionals.

The following questions pertain to Pediatric Interventional Radiology Practice.