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
clinical trials?
Yes
No
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Clinical services supported by physicist, and approximate annual caseload:
Service
External beam therapy
Sub-category
Approx. annual #
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)
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Other services supported or provided by physicist:
Service
Diagnostic imaging
physics support
Detail
Diagnostic tube tests
Approx. annual #
Mammography units
CT units
MRI units
PACS (# viewing stations)
Nuclear medicine units
Radiation safety
Number of radioactive
materials licenses:
Serve as RSO?
Computer support
Yes
No
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
Physicists (including part-time consultant services)
# FTE
Incumbent
Consultant
Radiation oncologists
Nurses
Radiation therapists
Dosimetrists
Physics assistants
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Clinical Equipment:
Category
Linear accelerator 1
Description
Manufacturer:
MLC
Linear accelerator 2
Model:
On-board imaging
Manufacturer:
MLC
Electrons
Model:
On-board imaging
Electrons
Simulator 1
Conventional
CT simulator
Simulator 2
Conventional
CT simulator
HDR remote afterloading
Manufacturer:
Stereotactic radiosurgery
Manufacturer:
Other treatment systems
Co-60
Model:
-MLC
Orthovoltage / superficial X-Ray
Permanent brachytherapy sources
TPS 1
Manufacturer:
3DCRT
TPS 2
Record & verify system
IMRT
Manufacturer:
3DCRT
# workstations:
Model:
LDR
HDR
# workstations:
Model:
IMRT
LDR
Manufacturer:
HDR
# 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.
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