DD Form 2164 X-Ray Verification Worksheet Guide – DD Form 2164 is the official Department of Defense form titled X-Ray Verification/Certification Worksheet. The current edition is dated February 24, 2025 (FEB 25). It is managed by the Department of the Army and published through the Washington Headquarters Services (WHS) Executive Services Directorate Forms Management Program.
This two-page worksheet is used exclusively to document the calibration, verification, and certification (CVC) of diagnostic X-ray equipment, including radiographic, fluoroscopic, and computed tomography (CT) systems in military medical facilities.
Purpose of DD Form 2164
The primary purpose of DD Form 2164 is to provide a standardized record of visual inspections, operational tests, and performance measurements performed on X-ray systems. Completing the form ensures that equipment operates within manufacturer specifications and federal safety standards, protecting both patients and operators from unnecessary radiation exposure while maintaining diagnostic image quality.
According to Army technical guidance (TB MED 750-2), results of all X-ray CVC services must be recorded on DD Form 2164. The completed form is retained in the Radiation Protection Program File (RPPF) for one year or until the next calibration is performed.
Who Uses DD Form 2164 in the United States?
DD Form 2164 is used by:
- Biomedical equipment technicians (BMETs) and medical equipment repairers (MERs) in Army, Navy, Air Force, and Defense Health Agency facilities
- Military medical treatment facilities (MTFs) and dental clinics performing preventive maintenance checks and services (PMCS)
- Contractors authorized to perform X-ray calibration services for DoD installations
The form is required whenever diagnostic X-ray equipment undergoes scheduled or unscheduled verification and certification.
Key Sections of DD Form 2164
The current FEB 2025 edition is organized into five main sections:
- Section I – Equipment Identification: Records manufacturer, model, serial numbers, and details for master control, room control, radiographic tubes, and fluoroscopic tubes.
- Section II & III – Visual Inspection of Equipment: Checklist items covering certification labels, high-tension cables, counterweight cables, interlocks, beam-limiting devices, overload protection circuits, and anode stator brake operation.
- Section IV – Radiographic Certification: Includes single-phase and three-phase line voltage and line-drop tests, transformer balance, exposure timer accuracy, kilovoltage and milliamperage verification tables (20–150 kVp), penetrometer film density evaluation, and phototimer tests.
- Section V – Fluoroscopic Certification: Covers kilovoltage verification, automatic brightness control, spot-film kVp and mA checks, fluoroscopic timer tests, and phototimer performance.
Spaces are provided for location (building and room number), date and time of service, date next service is due, action taken, and the inspector’s printed name, grade, and signature.
How to Complete DD Form 2164 Correctly
Follow these steps based on official Army guidance:
- Perform all required visual inspections and operational tests using calibrated test, measurement, and diagnostic equipment (TMDE).
- Record measured values directly on the form. Mark “Required,” “Not Required,” or “Action Taken” as applicable.
- Attach a separate sheet listing the manufacturer, model, serial number, and calibration expiration date of every piece of TMDE used during the service.
- Indicate whether results are satisfactory or unsatisfactory for film density, brightness control, and timer tests.
- Complete the “Inspected by” block with name, grade, and signature.
- Upon successful completion, affix a completed DD Form 2163 (Medical Equipment Verification/Certification label) to the equipment.
Previous editions of the form are obsolete and should not be used.
Download the Official DD Form 2164 (Current Edition)
The only official source for DD Form 2164 is the Washington Headquarters Services Forms website. Always download the latest version directly from the government portal to ensure compliance.
Official Download Link:
https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2164.pdf
Form page: https://www.esd.whs.mil/Directives/forms/dd2000_2499/DD2164/
For questions regarding use of the form, contact the Department of the Army Forms Management Branch at [email protected].
Related Forms and Regulatory References
- DD Form 2163 – Medical Equipment Verification/Certification label (affixed to the equipment after successful CVC)
- TB MED 750-2 – Maintenance Management Procedures for Medical Equipment (prescribes use of DD Form 2164 for X-ray systems)
- AR 40-61 – Medical Logistics Policies (addresses medical equipment maintenance requirements)
Why Accurate Completion of DD Form 2164 Matters
Proper use of DD Form 2164 supports radiation safety, regulatory compliance with the Radiation Control for Health and Safety Act, and high-quality diagnostic imaging across U.S. military healthcare facilities. Incomplete or outdated documentation can result in equipment being removed from service and may affect accreditation or inspection outcomes.
By following the official worksheet and retaining records as required, medical maintenance personnel help ensure that every X-ray system used on service members, retirees, and their families meets rigorous performance and safety standards.