AAPM TG103 Report

QA PROGRAM QUESTIONNAIRE

DATE:

Facility Name:	Physicist name:

Description	Score	Comment
A clearly documented procedure exists for annual calibration, monthly verification and daily constancy checks of dose output from accelerators and other therapy machines, consistent with the guidelines in TG-40 (ref. 2).	Yes No
A clearly documented procedure exists for verification of brachytherapy source strengths. The brachytherapy physics program is consistent with the recommendations of AAPM TG 56, 59, 60, and 64 reports (ref. 3-6).	Yes No
A clearly documented procedure exists for verification of TPS output and all monitor unit calculations, and routine TPS QA is performed consistent with the approach recommended by TG-53 (ref. 9).	Yes No
Patients’ treatment records are checked weekly by the physicist or a designee, and reviewed at the end of treatment by the physicist.	Yes No
The geometric precision and mechanical integrity of all clinical machines (accelerators, simulators, etc) are verified regularly, consistent with the recommendations in TG-40.	Yes No
The accelerators’ output calibrations are verified annually by an independent method (e.g., RPC or RDS TLD, or independent physicist’s calibration).	Yes No
The physicist annually reviews the physics and radiation safety program, and reports the findings of this review to the medical director and administrator.	Yes No

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