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Mammography Accreditation Program
Test Image Data
1891 Preston White Drive, Reston, VA 20191-4397
This form is used to record the technical factors used for the phantom and clinical images. Complete a separate form for each
mammography unit being evaluated. All information on this sheet must be accurate and complete. If you are applying online, enter the
data in your online Testing Package at: https://acredit.acr.org.
PRIVILEGED and CONFIDENTIAL • PEER REVIEW
Code of Virginia 8.01-581.17
GENERAL
Person completing form:
Telephone: (
)
Date:
Mammography unit room #:
Mammography unit manufacturer:
Mammography unit model name:
Year manufactured:
Computed radiography manufacturer (FFDM-CR only):
Computed radiography model (FFDM-CR only):
Primary interpretations are from (FFDM only): check one
soft copy
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SYSTEM IDENTIFICATION
hard copy
REVIEW WORKSTATION (FFDM only)
Manufacturer:
Model:
FILM PRINTER (FFDM only)
Manufacturer:
Model:
If hard copy printed by third party, identify party:
SCREEN-FILM PROCESSOR (screen-film only)
Screen manufacturer and type:
Film manufacturer and type:
Film processor manufacturer:
Film processor model:
Total processor cycle time:
seconds
Developer temperature:
° Fahrenheit
Chemistry manufacturer:
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This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of
the American College of Radiology is prohibited.
Page 1 of 3
S:\MammoMaster\Test Materials Pkg\TEST IMAGE DATA.docx
Revised: 11-30-15
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MAP ID No.
PHANTOM IMAGE
Phantom:
Gammex (RMI) Model 156
Nuclear Associates (Fluke) Model 18-220
Phantom serial number (on side of phantom):
CIRS Model 015
Wax insert serial number (appears on image):
Phantom image background optical density (hard copy only):
Technical factors used to produce the phantom image (circle appropriate choices; indicate “NA” if not applicable):
General Electric and Philips (Sectra) FFDM Systems Only
Phantom
Exposure
Date
AEC
Mode
kVp
Time
mAs
sec
msec
AEC exposure
Manual exposure
Tube Target
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
sec
msec
***
Nominal
(after exposure) (after exposure) Focal Spot
Filter
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
All Other Mammography Systems
Phantom
Exposure
Date
AEC
Mode
AEC
Manual
kVp
Time
mAs
Nominal
(after exposure) (after exposure) Focal Spot
sec
msec
Tube Target
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Filter
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
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Do NOT Submit This Form
Do NOT Submit This Form
This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of
the American College of Radiology is prohibited.
Page 2 of 3
S:\MammoMaster\Test Materials Pkg\TEST IMAGE DATA.docx
Revised: 11-30-15
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MAP ID No.
CLINICAL IMAGES
Only submit cases from actual patients that have been formally interpreted as "negative" (BI-RADS® Assessment Category 1). Do
not submit “benign” (Category 2) or “incomplete” (Category 0) cases. Images must be labeled with the MQSA-required
identification information; this will be evaluated by the reviewer.
- Submit both fatty and dense cases for INITIAL, RENEWAL or REINSTATE accreditation.
- If you are REPEATING this test for a clinical accreditation deficiency, you must submit both fatty and dense cases performed after
the date on your DEFICIENCY REPORT.
- For VALIDATION FILM CHECKS, you may submit cases of any density. After a validation film check clinical deficiency, only one case
of any density is required.
Technical factors (circle appropriate choices; indicate “NA” if not applicable):
Fatty breast
Validation film check
Date of
Exam
View
Left CC
lb
daN
N
kg
cm
mm
Right MLO
_____degrees
oblique
lb
daN
N
kg
cm
mm
Left MLO
_____degrees
oblique
lb
daN
N
kg
Dense breast
Date of
Exam
kVp
Time
(after exposure)
mAs
sec
msec
cm
mm
Nominal
Focal Spot
Tube Target
Filter
Molybdenum (Mo)
Molybdenum (Mo)
Rhodium (Rh)
mm
Rhodium (Rh)
Aluminum (Al)
Tungsten (W)
Silver (Ag)
sec
msec
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
sec
msec
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
sec
msec
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
Validation film check
View
Right CC
Compression
Compressed
Force
Breast Thickness
lb
daN
cm
N
mm
kg
kVp
Time
(after exposure)
mAs
sec
msec
Nominal
Focal Spot
Tube Target
Filter
Molybdenum (Mo)
Molybdenum (Mo)
Rhodium (Rh)
mm
Rhodium (Rh)
Aluminum (Al)
Tungsten (W)
Silver (Ag)
Left CC
lb
daN
N
kg
cm
mm
sec
msec
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
Right MLO
_____degrees
oblique
lb
daN
N
kg
cm
mm
sec
msec
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
Left MLO
_____degrees
oblique
lb
daN
N
kg
cm
mm
sec
msec
Molybdenum (Mo)
mm
Rhodium (Rh)
Tungsten (W)
Molybdenum (Mo)
Rhodium (Rh)
Aluminum (Al)
Silver (Ag)
This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of
the American College of Radiology is prohibited.
Page 3 of 3
S:\MammoMaster\Test Materials Pkg\TEST IMAGE DATA.docx
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Revised: 11-30-15
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Right CC
Compression
Compressed
Force
Breast Thickness
lb
daN
cm
N
mm
kg