Request for approval of study or procedure using

DXA (Dual Energy X-Ray Absorptiometry)

for assessment of body composition and/or bone mineral density (BMD).

This form is to acquire approval to conduct any new research, diagnostic or experimental procedure involving DXA radiation exposure to staff and project participants.

A copy of the study application or procedure protocol that will be submitted to the

AIS Ethics Committee must be attached.

Name
Organisation
Email
Phone
Project Title
Date of commencement
Site of DXA assessments
Type of DXA equipment
Radiation safety plan/oversight	Provide details of protocols used to ensure safety.
Quality assurance/ Control program	Provide details of protocols used to ensure machine accuracy.
Body composition assessment protocol	Describe protocols used to ensure measurement precision.
Bone mineral density (BMD) assessment protocol	Describe protocols used to ensure measurement precision.
Number and type of participants in current project
Number of body composition assessment scans per participant
Justification for the number & duration between body composition scans
Number of BMD scans/participant
Justification for the number & duration between BMD scans
Exclusion criteria for the use of DXA
Other comments
Total radiation dose
Ethics submission is attached
Signature
Date

Please forward this form to Dr Don McLean

Radiation Safety Advisor (Diagnostic Radiology)

02 6174 5623 or email CHS.DRPhysics@act.gov.au

Medical Dose Report

*To be completed by relevant Radiation Safety Advisor.

Report
Comments
Recommendations (Mark with ‘ X ’)	Approved
Not approved
Name
Signature
Date