AAPM TG103 Report

FACILITY INFORMATION CHECKLIST

This can be completed by the incumbent physicist prior to the reviewer’s on-site visit, and mailed to the reviewer. In this case, the reviewer would only need to verify the information on site.

DATE:

Facility Name:

Street Address:

City, State, Zip:

Mailing address:	Check if same as facility address

Street Address:

City, State, Zip:

Telephone:	Fax:

E-mail:

Physicist name:

Clinic type:	Hospital based	Free standing

Single location	Multiple locations

Academic affiliation?	Yes	No

Participate in national	Yes	No

clinical trials?

AAPM TG103 Report

Clinical services supported by physicist, and approximate annual caseload:

Service	Sub-category	Approx. annual #
External beam therapy	2D conventional
3DCRT
IMRT
Stereotactic guided radiosurgery/radiotherapy
Image-guided radiotherapy

System:
Total body irradiation
Brachytherapy	LDR temporary
Prostate seed implants
HDR
IVBT
Radiopharmaceutical therapy
Intraoperative therapy
Other (describe)

AAPM TG103 Report

Other services supported or provided by physicist:

Service	Detail	Approx. annual #
Diagnostic imaging physics support	Diagnostic tube tests
Mammography units
CT units
MRI units
PACS (# viewing stations)
Nuclear medicine units
Radiation safety	Number of radioactive materials licenses:
Serve as RSO?	Yes No
Computer support	Number of workstations
Type of support:	Networking

Applications
Administrative	Employees supervised
Responsible for physics billing policies/audits?	Yes No
Teaching responsibilities?	Yes No

Staffing levels:

Position	# FTE
Physicists (including part-time consultant services)	Incumbent

Consultant
Radiation oncologists
Nurses
Radiation therapists
Dosimetrists
Physics assistants

AAPM TG103 Report

Clinical Equipment:

Category	Description
Linear accelerator 1	Manufacturer: Model:

MLC On-board imaging Electrons
Linear accelerator 2	Manufacturer: Model:

MLC On-board imaging Electrons
Simulator 1	Conventional CT simulator
Simulator 2	Conventional CT simulator
HDR remote afterloading	Manufacturer: Model:
Stereotactic radiosurgery	Manufacturer: (-MLC
Other treatment systems	Co-60 Orthovoltage / superficial X-Ray

Permanent brachytherapy sources
TPS 1	Manufacturer: Model:

3DCRT IMRT LDR HDR	# workstations:

TPS 2	Manufacturer: Model:

3DCRT IMRT LDR HDR	# workstations:

Record & verify system	Manufacturer:	# workstations:

Comments: Describe anything about the facility that is not properly conveyed in the spaces above. Also, any specific aspects of the clinical physics program that the on-site physicist wishes to have the reviewer focus on in addition to the core review components.

Privileged and Confidential Peer Review

Privileged and Confidential Peer Review

Privileged and Confidential Peer Review

Privileged and Confidential Peer Review

AAPM TG103 Report - Facility checklist

Mechanisms for Peer Review in Clinical Radiation Oncology Physics

Peer review, professional

Facility checklist form

Per Halvorsen

2005-03-17

Ravi Rao

AAPM