IAC Nuclear/PET
Equipment Form & Instrumentation Table
Facilities requesting a change in equipment should submit the following form.
Facility Name:
Application #:
Section 1B: Instrumentation and Equipment
For each imaging system, complete the table below. This form can be used to list three imaging systems. If more
space is needed to list additional equipment use the separate “Additional Forms” file for additional instrumentation
tables.
Instrumentation Table
IMAGING SYSTEMS
Manufacturer
#1
#2
#3
Model
Year of manufacture
SPECT or planar
Number of detectors
PET (Gamma or dedicated)
Full or partial ring
Acquisition computer
Processing computer
Display computer
Stationary or mobile
Preventative maintenance
IAC Nuclear/PET Equipment & Instrumentation Table
Reviewed 11/2014
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