AAPM TG103 Report

PHYSICS INSTRUMENTATION 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:	Physicist name:

Category	Description	Cal. Date & Institution
Ionization chamber 1	Manufacturer: Model:
Ionization chamber 2	Manufacturer: Model:
Ionization chamber 3	Manufacturer: Model:
Electrometer 1	Manufacturer: Model:
Electrometer 2	Manufacturer: Model:
Scanning dosimetry system (“water tank”)	Manufacturer: Model:

2D 3D Multi-detector array
Film dosimetry	Manufacturer: Model:

Film scanner model:
Calibration phantom	Material: Poly Acrylic Solid H2O Water

Protocol: TG-21 or TG-51
In-vivo dosimetry 1	Manufacturer: Model:
In-vivo dosimetry 2	Manufacturer: Model:
Special-purpose phantom (e.g., RPC anthropomorphic, “hybrid IMRT”, etc.)	Manufacturer:

Model/description:
Other	Describe:
Thermometer(s) (quantity)	Mercury column Thermocouple

Alcohol Thermistor
Barometer(s) (quantity)	Mercury column ( Are appropriate temperature and

gravity (latitude) corrections applied?

Aneroid Digital

Privileged and Confidential Peer Review

AAPM PICR - TG103 Report

Mechanisms for Peer Review in Clinical Radiation Oncology Physics

Peer review, professional

Per H Halvorsen

2005-03-17

Ravi Rao