ÿþ <html> <body> <fieldset> <legend> SAMs Florida Chapter AAPM: Diagnostic/General SAM (Image Gently) </legend> <br> <b>*PLEASE FILL OUT ALL FIELDS*</b> <form action="MAILTO:amish.shah@orlandohealth.com;thomas.wagner@orlandohealth.com" method="post" enctype="text/plain"> <input type="hidden" name="Which SAM?" value="Image Gently"> <br> First name: <input type="text" name="firstname"> <br> Last name: <input type=" text" name="lastname"> Suffix: <input type=" text" name="suffix" size="14"> <br> Company: <input type=" text" name="company" size="46"> <br> Title(s): <input type=" text" name="title" size="49"> <br> Mailing Address: <input type=" text" name="address" size="40"> <br> Mailing Address: <input type=" text" name="address" size="40"> <br> City: <input type=" text" name="city" size="20"> State: <input type=" text" name="state" size="10"> Zip: <input type=" text" name="zip" size="10"> <br> Phone Number: <input type=" text" name="phone" size="44"> <br> Email Address: <input type=" text" name="email" size="45"> <br> <br> <b>Please indicate ONE best answer for each question (if you make a mistake, click "RESET" at the bottom of this page):</b> <br> <br> <b>Q1. The goal of the Image Gently Campaign is</b> <br> <INPUT TYPE=RADIO NAME="(1)" value="a1"> (A) to raise awareness of the opportunities to lower radiation dose in the imaging of children <br> <INPUT TYPE=RADIO NAME="(1)" value="b1"> (B) provide a forum for professional societies to interact directly with CT manufacturers <br> <INPUT TYPE=RADIO NAME="(1)" value="c1"> (C) support the development of more strict regulatory standards for pediatric doses <br> <INPUT TYPE=RADIO NAME="(1)" value="d1"> (D) provide CT protocols that will meet the ACR CT accreditation pass/fail requirements for CT dose <br> <INPUT TYPE=RADIO NAME="(1)" value="e1"> (E) to raise funds to support further research into medical radiation effects to children <br> <br> <b>Q2. The excess cancer risk from CT examinations are generally expected to</b> <br> <INPUT TYPE=RADIO NAME="(2)" value="a2"> (A) decrease with decreasing age of exposure and increase with increasing attained age <br> <INPUT TYPE=RADIO NAME="(2)" value="b2"> (B) decrease with increasing age of exposure and increase with increasing attained age <br> <INPUT TYPE=RADIO NAME="(2)" value="c2"> (C) increase with increasing age of exposure and decrease with increasing attained age <br> <INPUT TYPE=RADIO NAME="(2)" value="d2"> (D) increase with both increasing age of exposure and increasing attained age <br> <INPUT TYPE=RADIO NAME="(2)" value="e2"> (E) decrease with both increasing age of exposure and increasing attained age <br> <br> <b>Q3. The Alliance for Radiation Safety in Pediatric Imaging recommends a technique to develop CT protocols for children based on</b> <br> <INPUT TYPE=RADIO NAME="(3)" value="a3"> (A) a set of tabulated values of kVp, mAs, and pitch for various sizes of pediatric patients. <br> <INPUT TYPE=RADIO NAME="(3)" value="b3"> (B) incorporating mA modulation into routine scanning protocols. <br> <INPUT TYPE=RADIO NAME="(3)" value="c3"> (C) scaling the kVp from adult protocols to specific patient sizes. <br> <INPUT TYPE=RADIO NAME="(3)" value="d3"> (D) scaling the mAs from adult protocols to specific patient sizes. <br> <INPUT TYPE=RADIO NAME="(3)" value="e3"> (E) incorporating appropriate bow-tie filters and increasing the pitch for pediatric scans. <br> <br> <b>Q4. The ACR Accreditation Dose Requirements for the Pediatric Abdomen (5 yr old) is 25 mGy of the measured quantity</b> <br> <INPUT TYPE=RADIO NAME="(4)" value="a4"> (A) CTDI<sub>100 </sub> <br> <INPUT TYPE=RADIO NAME="(4)" value="b4"> (B) CTDI<sub>W </sub> <br> <INPUT TYPE=RADIO NAME="(4)" value="c4"> (C) CTDI<sub>VOL </sub> <br> <INPUT TYPE=RADIO NAME="(4)" value="d4"> (D) DLP <br> <INPUT TYPE=RADIO NAME="(4)" value="e4"> (E) Effective Dose <br> <br> <b>Q5. Based on the following table, a facility that uses an Adult Head protocol of 120 kVp, 250 mAs, pitch=1, the  Image Gently CT protocol for a 1 yr old patient would be</b> <br> <br> <img src="image002.jpg" width="285" height="387" border="2" align="absmiddle"> <br> <br> <INPUT TYPE=RADIO NAME="(5)" value="a5"> (A) 120 kVp, 125 mAs, pitch = 1 <br> <INPUT TYPE=RADIO NAME="(5)" value="b5"> (B) 120 kVp, 200 mAs, pitch = 1 <br> <INPUT TYPE=RADIO NAME="(5)" value="c5"> (C) 100 kVp, 250 mAs, pitch = 2 <br> <INPUT TYPE=RADIO NAME="(5)" value="d5"> (D) 100 kVp, 125 mAs, pitch = 0.5 <br> <INPUT TYPE=RADIO NAME="(5)" value="e5"> (E) 80 kVp, 250 mAs, pitch = 1 <br> <br> <b>If you have not already paid via Paypal, please acknowledge you must first make payment to receive any SAMs credit</b> <br> <INPUT TYPE=RADIO NAME="Paypal" value="Paypal"> Okay, I will now proceed to PayPal. <br> <INPUT TYPE=RADIO NAME="Paypal" value="Attendee"> N/A, I have already paid! <br> <br> <br> <b>IMPORTANT note: when you press "Submit", please allow email YOUR server to send an email!</b> <br> <br> <name="input" action="html_form_action.asp" method="get"> Comments: <input type="text" name="user comments " size="45"> <input type="submit" value="Submit"> <input type="Reset" value="Reset"> </form> </body> </html>