6-Month X-ray Safety Test Checklist X-Ray Safety Device Test Regulations require Testing of Safety Devices for Radiation Generating Devices every 6 months, DHS 157.87(1)(j) Interlocks Working?(Required) Yes No N/A Shutter "Open" Warning Lights Working?(Required) Yes No N/A Warning Lights Indicating X-rays are "On" Working?(Required) Yes No N/A Emergency Shut-Off Button Working?(Required) Yes NO If any safety device fails during testing, the radiation generating device shall be removed from service until the safety device failure is corrected or proper temporary administrative controls are established and approved in writing by the person in control. Corrective Actions: Name(Required) Building/Room Number(Required) Device(s) Being Tested: (example Bruker D8, CT Scanner, etc.) Date(Required) MM slash DD slash YYYY Survey Instrument (if used) -Leak tests will be performed at the Annual Radiation Safety X-ray Inspections in April or after the device has been serviced. Survey Meter Calibration Date: