Form 7 CTSU Radiation Therapy Facilities Inventory Form

Attachment_1g_rtform
Attach_1f_RTFORM

OMB#0925-0624
Expiration Date: 12/31/2013

Public reporting burden for this collection of information is estimated to average 30 minutes per response,
Public the
reporting
burden
for this
collection searching
of information
is estimated
to gathering
vary from and
20 to
60 minutes
including
time for
reviewing
instructions,
existing
data sources,
maintaining
theper
dataresponse,
including
the time forand
reviewing
instructions,
searching
existing data
sources,
andormaintaining
the data
needed,
and completing
reviewing
the collection
of information.
An agency
maygathering
not conduct
sponsor, and
needed,
andrequired
completing
and reviewing
the collection
of information.
agencyamay
not conduct
or sponsor, and
a person
is not
to respond
to, a collection
of information
unless An
it displays
currently
valid OMB
a person
is not
to regarding
respond to,
collection
of information
it this
displays
a currently
valid OMB
control
number.
Sendrequired
comments
thisaburden
estimate
or any other unless
aspect of
collection
of information,
controlsuggestions
number. Send
comments
thisNIH,
burden
estimate
or anyBranch,
other aspect
of this collection
information,
including
for reducing
thisregarding
burden, to:
Project
Clearance
6705 Rockledge
Drive,ofMSC
7974,
Bethesda,
MD
20892-7974,
DoProject
not return
the completed
this address.
including
suggestions
for ATTN:
reducingPRA
this (0925-0624).
burden, to: NIH,
Clearance
Branch,form
6705toRockledge
Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0624). Do not return the completed form to this address.

Filling out PDF Forms
This PDF form contains “roll-over or double-click ” help functionality.
This form allows you to enter data directly onto the screen. After completing the form,
you are able to print the document so that you can fax/mail the document.

To fill out a form:
1. Select the hand tool.
2. Position the pointer inside a field, and click to type text.
3. After entering text or selecting a check box, do one of the following:
- Press tab to accept the form field change and go to the next form field.
- Press Shift+Tab to accept the form field change and go to the previous form
field.
- Press Enter (Windows) or Return (Mac OS) to accept the form field change and
deselect the current form field.
4. Once completed, print the form.

OMB#0925-0624
Expiration Date: 12/31/2013

CTSU

Attachment_1g_rtform
Attach_1f_RTFORM

RT FACILITIES INVENTORY
NOTE:Radiation
RadiationTherapy
Therapy
facilities
participating
in NCI
sponsored
protocols
beinactive
in the
NOTE:
facilities
participating
in NCI
sponsored
protocols
must bemust
active
the Radiological
Radiological
Physics
Center
(RPC)
Quality
Assurance
monitoring
program.
Please
complete
facility
Physics Center (RPC) Quality Assurance monitoring program. Please complete the facility personnelthe
contact
and
personnel
peer
review
section
of this form
if your
participates
in theand
RPC
peer
reviewcontact
section and
of this
form
if your
site participates
in the
RPCsite
monitoring
program
faxmonitoring
it to the CTSU
program and
fax itatto
the CTSU
Regulatory
at 1-215-569-0206
to
Regulatory
Office
Westat
in Rockville,
MD atOffice
1-888-691-8039.
Sites thatordoe-mail
not currently
participate in the
monitoring
program must submit a complete six page form and all applicable supplemental documentation. The
CTSURegulatory@ctsu.coccg.org.
complete form and supplemental documentation should be mailed or couriered to the CTSU Regulatory Office in
Rockville,
at: currently participate in the monitoring program must submit a complete six page form and
Sites that MD
do not
Westatdocumentation. The complete form and supplemental documentation should be
all applicable supplemental
W. Montgomery Ave
faxed or emailed to the1441
CTSU
Regulatory Office.
Rockville, MD 20850
WB 365-A
CTSU requires a one time
of the Coordinator
RT information
Attn:submission
CTSU Regulatory
– RT for each facility used by your institution.
Changes
contact
should
made
using thisdocumentation.
form and clearlyCTSU
notedrequires
on the form.
Do
not usetothe
fax toinformation
send complete
formsbe
and
supplemental
a one time
submission of the RT information for each facility used by your institution. Changes to contact information should
be made using this form and clearly noted on the form.
Facility Information
Name _________________________________ Also known as/Formerly known as: ____________________________
RTF# from RPC: _______________ (available at RPC site: http://rpc.mdanderson.org/rpc/)
Address (street):
_____________________________________________________________________________________________
Address (city, state, zip):
Phone:

Fax:

Estimated Clinical Trials Case Load per year: __________________
List Institutions that this RT Facility Serves:
Name: __________________________________________________

CTEP ID: ________________

Name: __________________________________________________

CTEP ID: ________________

Name: __________________________________________________

CTEP ID: ________________

Name: __________________________________________________

CTEP ID: ________________

(Attach additional sheet if more lines are needed.)
Personnel
Radiation Oncologist Senior Investigator
Name
Address
CTSU_RTFI_v.7_04
(update07_2013)
5_2008)
CTSU_RTFI_v8 (update
authorized by CTSU for local reproduction
Page 1 of 6

Attachment_1g_rtform
Attach_1f_RTFORM

OMB#0925-0624
Expiration Date: 12/31/2013

CTSU
RT FACILITIES INVENTORY

Phone/Fax/E-mail _______________________________________________________________
CRA(s):
Name
Address
Phone/Fax/E-mail _______________________________________________________________
Radiation Oncologists
Name
Address
Phone/Fax/E-mail _______________________________________________________________
Physicist(s)
Name
Address
Phone/Fax/E-mail _______________________________________________________________
Dosimetrist(s)
Name
Address
Phone/Fax/E-mail _______________________________________________________________
Radiation Oncologist Therapists
Name _________________________________________________________________________
Address _________________________________________________________________________
Phone/Fax/E-mail ____________________________________________________________________
Peer review
Do you actively participate in RPC TLD monitoring program?

No

Yes

If Yes, Most Recent RPC Report Date_________________________
♣♣♣ (Stop – Do not complete the remainder of this form if your facility is RPC monitored] ♣♣♣

CTSU_RTFI_v.7_04(update
(update07_2013)
5_2008)
CTSU_RTFI_v8
authorized by CTSU for local reproduction
Page 2 of 6

OMB#0925-0624
Expiration Date: 12/31/2013

CTSU

Attachment_1g_rtform
Attach_1f_RTFORM

RT FACILITIES INVENTORY
Equipment
Megavoltage Machine(s)
Model

Manufacturer

Serial #

Date Installed

X-Ray Energy

Simulation Equipment:
Does your Radiation Oncology Department have a dedicated CT unit?

Yes

No

If yes, Model/Manufacturer: __________________________________
If no, list other simulation equipment/system manufacturer/model: __________________________________________
_______________________________________________________________________________________________
Ancillary Equipment
Is your institution equipped to perform stereotactic radiosurgery?
Is your institution equipped to perform HDR brachytherapy?

No

Yes

Is your institution equipped to perform MammoSite® treatments?

No

Yes

CTSU_RTFI_v.7_04
(update07_2013)
5_2008)
CTSU_RTFI_v8 (update
authorized by CTSU for local reproduction
Page 3 of 6

Yes

No

Electron
Energies

OMB#0925-0624
Expiration Date: 12/31/2013

CTSU

Attachment_1g_rtform
Attach_1f_RTFORM

RT FACILITIES INVENTORY
Is your institution equipped to perform LDR interstitial brachytherapy?

No

Yes

Does your institution have a method to calibrate brachytherapy sources?

No

Yes

Is your institution equipped to perform IMRT?

No

Yes

If yes, what isotopes: ________________________________

If yes, what is your treatment planning system? _______________________________________
_____________________________________________________________________________
If yes, what is your dose delivery technique? __________________________________________
_______________________________________________________________________________
Does your institution use a record and verify system?

No

Yes

If yes, what type: _________________________________________________________________
Isodose Plotter/Water Phantom
If Yes, Type:__________________________________

No

Yes

No

Yes

Photon

Electron

Manufacturer:____________________________
Detector:________________________________
Film Densitometer
If Yes, Manufacturer:____________________________
Institution’s Standard Dosimeter for beam calibration
Type
Ion chamber: ____________________________

Date of last NIST traceable calibration
___/____/____

Electrometer: ____________________________

___/____/____

Has your institution converted to the TG-51 calibration protocol?

No

If yes, on what date: ____/____/20____
If no, specify the calibration protocol you currently use. ______________________________
___________________________________________________________________________

Treatment Planning
CTSU_RTFI_v8 (update
CTSU_RTFI_v.7_04
(update07_2013)
5_2008)
authorized by CTSU for local reproduction
Page 4 of 6

Yes

OMB#0925-0624
Expiration Date: 12/31/2013

CTSU

Attachment_1g_rtform
Attach_1f_RTFORM

RT FACILITIES INVENTORY
External beam treatment planning computer?

No

Yes

No

Yes

No

Yes

Isodose Distributions: Multiple planes?

No

Yes

Does your facility have the capability to complete electronic data
transmission to the Image-guided Therapy Center (ITC) or other
organizations?

No

Yes

Typically recorded daily doses:
Gross Tumor Volume
Critical Organs
Time of Treatment

No
No
No

Yes
Yes
Yes

Do you have the ability to treat all fields daily for a protocol patient?

No

Yes

If Yes, Make:__________________________________
Model:__________________________________
Version:________________________________
2D

3D

Treatment Planning Computer for brachytherapy
If Yes, Make:__________________________________
Model:_________________________________
CT Treatment planning system?
If Yes, Manufacturer:___________________________

Treatment Record

CTSU_RTFI_v.7_04(update
(update07_2013)
5_2008)
CTSU_RTFI_v8
authorized by CTSU for local reproduction
Page 5 of 6

CTSU

Attachment_1g_rtform
Attach_1f_RTFORM

OMB#0925-0624
Expiration Date: 12/31/2013

RT FACILITIES INVENTORY
Quality Assurance
Briefly describe the QA program in existence at facility to verify equipment performance (please summarize
parameters and frequency of checks).

Briefly describe the procedure utilized for assuring accuracy of each individual patient’s initial dose calculations
(timer/monitor units).

Who is responsible for chart checking and how often is it done?

How often are portal and/or verification films taken for each patient?

Attachments:
•

Last annual full calibration report for each treatment machine that will be used in protocol studies.

•

Sample of Daily Treatment Record

•

Most recent TLD check if available

•

Facility Quality Assurance plan &/or sample documents

Signature of Radiation Oncologist: ___________________________________
Signature of Physicist: _____________________________________________
Date: ____/_____/20_____

CTSU_RTFI_v.7_04(update
(update07_2013)
5_2008)
CTSU_RTFI_v8
authorized by CTSU for local reproduction
Page 6 of 6