Equipment Orientation and Applications Training – Pre-Consultation Questions

This form must be filled out prior to your consultation. Please email Jen Neely if you have any questions: jen@mammographyeducators.com

Name of Third Party Vendor*

Name of Contact Completing this Questionnaire*

First Last

Equipment Information

Make*

Model*

Year*

Date of Equipment Installation

Date of Physicist Evaluation/Testing

Contact Information

Client Contact Name*

First Last

Client Contact Phone*

Client Contact Email*

Client Contact Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Training Information

Training Site Name (where the training will be held)*

Facility Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please provide any parking instructions or directions to the building (if applicable) that the consultant should be aware of*

Are there any visitor or vendor requirements that your consultant will need to complete prior to training, such as: sign-in processes, documentation or verification requirements, etc? Please provide specific details, if applicable.*

Name of the individual who will be meeting the consultant on the first day of training*

First Last

What is the best contact number for the individual listed above?*

Service Engineer Information

Service Engineer's Name*

First Last

Service Engineer's Phone*

Service Engineer's Email*

The service engineer will be on-site for the first day of training and readily available on the required training day(s).

If not, please explain:*

The service engineer will ensure connectivity and transmission of images for storage and interpretation before training begins.

If not, please explain:*

Please confirm that the following necessary accessories and equipment will be on-site and available for use:

Phantom:*

If no, please explain why:*

Acrylic Flat Field Phantom:*

If no, please explain why:*

Archival Media (USB):*

If no, please explain why:*

Printed Manufacturer's or ACR QC manual:*

If no, please explain why:*

Printed Manufacturer's User Manual:*

If no, please explain why:*

Printed QC Forms/Binder:*

If no, please explain why:*

Additional Information

Any additional information/details we should know?

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