Peripheral Venous Testing Section (Add On)
This form is to be used for add on testing sections for accredited IAC Vascular Testing facilities only. If your facility
is not currently accredited or is in the review process, please contact the IAC office before filling out this form.
If this is a screening service applying in accreditation of medical screening (CAMS), please contact the IAC office
before filling out this form. Please answer all questions. Required attachments will be indicated by the  symbol.
Name of institution (as listed on the Accreditation Agreement):
(This institution name will be tracked in the IAC database and will receive all IAC correspondence)
Application #:
Department:
Street address 1:
Street address 2:
City:
State:
Zip code:
Location of vascular facility:
Hospital
Private office
Free-standing imaging center
Independent facility
Other (please specify):
Which of the following are available to deal with medical emergencies?
Oxygen/airway
Emergency drugs
Defibrillator
Fully-equipped crash cart
Medical physician
Registered nurse
In the initial evaluation of lower extremity peripheral venous disease which of the following are routinely performed
as your primary examination? (The primary examination is the examination type with the highest volume.)
Lower extremity duplex examination for venous patency
Lower extremity duplex examination for venous reflux
Indications (Applicable Standard – 4.1B)
Are appropriate indications for the examination documented prior to performing the examination?
Yes
No
If no, please explain:
Equipment (Applicable Standard – 4.2B)
Venous duplex – Does the equipment provide the following:
1.
A range of imaging frequencies appropriate for the structures evaluated?
Yes
2.
No
Doppler frequencies appropriate for the vessels evaluated?
Yes
No
Peripheral Venous Testing Section (Add On)
Reviewed 5/2015
1
3.
Range-gated Doppler capability?
Yes
4.
A measureable and adjustable Doppler angle?
Yes
5.
No
No
A visual display, audible output, and permanent record capabilities?
Yes
No
Protocols and Diagnostic Criteria (Applicable Standards- 4.3B/3.4A)

Lower extremity peripheral venous duplex examination for venous patency: If performed submit a detailed
technical protocol and referenced diagnostic criteria.
Protocol:
Criteria:

Attached
Attached
N/A
N/A
Lower extremity peripheral venous duplex examination for venous reflux: If performed submit a detailed
technical protocol and referenced diagnostic criteria.
Protocol:
Criteria:
Attached
Attached
N/A
N/A
Quality Improvement (QI) (Applicable Standard – 1.1C)

QI Policy: Submit a copy of the facility QI policy.
Attached

QI Log: Submit the QI log including data collected over the past three years documenting a minimum of 30
extremity correlations, demonstrating greater than 70% accuracy.
(Visit intersocietal.org/vascular/seeking/sample_documents.htm to download a sample log.)
Attached
Please select from the list below what venous examinations are correlated to:
Repeat examination performed within three days of the initial exam
Clinical outcome
Case peer review by a second interpreting physician that includes comments regarding: technical adequacy,
interpretation accuracy and final report completeness
Venography
Surgical findings
Enter the overall accuracy percentage of the appropriate validating studies:
Procedure Volumes (Applicable Standard – 4.7B)
Enter the volumes for the examinations performed in the facility within the past 12 operational months. Include in
the total, all volumes from any multisite and mobile services, if applicable. If the facility has been in operation less
than 12 months, volumes must still be entered.
1.
Number of years that the facility has been performing lower extremity peripheral venous services:
2.
Lower extremity venous duplex for patency annual volumes:
3.
Lower extremity venous duplex for reflux annual volumes:
Peripheral Venous Testing Section (Add On)
Reviewed 5/2015
2
Peripheral Venous Case Study Instructions
Case study submissions are required in order to assess the interpretative and technical quality of the facility. All of
the details of the vascular anatomy should be visualized adequately.









Cases must represent best work
All cases must be abnormal of varying degrees of pathology
All medical and technical staff must be represented at least once before repeating
The Technical Director and Medical Director must be represented
All cases must be selected from within the past 12 months from the date of application filing
Submit one copy of all case studies/case study materials to the IAC office afterfinal submission.
Label all media with patients’ names or identification, and testing section.
Cases must represent as many staff as possible. When selecting and submitting case studies, do not
duplicate staff members (medical and technical) until all staff have been represented at least once.
All cases must be submitted in digital format (CD, DVD, flash drive) including the embedded imagespecific reader (DICOM viewer).
Case Study Submission Requirements
Primary Site Case Study Submission Requirements
(if an application includes only one site):
Primary Examination | Submit a total of three representative patient examinations; all must be abnormal. The
primary examination type is the examination type with the highest volume. If reflux only, three reflux cases will be
required. If patency and reflux are performed - 2 reflux (if reflux is primary) and 1 patency case; or 2 patency (if
patency is primary) and 1 reflux case will be required. If patency only, two patency case studies must be submitted
and if performed, the third case study must be chosen from the list below:"
Upper extremity venous duplex for patency
Dialysis Access graft duplex
Lower extremity duplex for patency (if not primary)
Lower extremity duplex for reflux (if not primary)
If no additional testing is performed, submit a third primary case study
Additional Testing: If performed, submit a detailed technical protocol and referenced diagnostic criteria for the
third case study chosen above.
Protocol:
Criteria:
Attached
Attached
N/A
N/A
Multiple Site Case Study Submission Requirements (if an application includes one or more multiple sites):

Primary Examination | Submit one abnormal case for each testing section the facility is apply in.
Peripheral Venous Testing Section (Add On)
Reviewed 5/2015
3