Form 6 Attach 1F - CTSU Radiation Therapy Facilities Inventory

Attach_1f_RTFORM

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

Public reporting burden for this collection of information is estimated to vary from 20 to 60 minutes per response,
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including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

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OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

CTSU

Attach_1f_RTFORM

RT FACILITIES INVENTORY
NOTE: Radiation Therapy facilities participating in NCI sponsored protocols must be active in the Radiological
Physics Center (RPC) Quality Assurance monitoring program. Please complete the facility personnel contact and
peer review section of this form if your site participates in the RPC monitoring program and fax it to the CTSU
Regulatory Office at Westat in Rockville, MD at 1-888-691-8039. Sites that do not currently participate in the
monitoring program must submit a complete six page form and all applicable supplemental documentation. The
complete form and supplemental documentation should be mailed or couriered to the CTSU Regulatory Office in
Rockville, MD at:
Westat
1441 W. Montgomery Ave
Rockville, MD 20850
WB 365-A
Attn: CTSU Regulatory Coordinator – RT
Do not use the fax to send complete forms and supplemental documentation. CTSU requires 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 (update 5_2008)
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Attach_1f_RTFORM

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

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 5_2008)
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OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

CTSU

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 (update 5_2008)
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Yes

No

Electron
Energies

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

CTSU

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_v.7_04 (update 5_2008)
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Yes

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

CTSU

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 5_2008)
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CTSU

Attach_1f_RTFORM

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

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_____

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