PET/CT Equipment Questionnaire
Imaging Facility Name:
Ship-To Address:
City:
State/Province :
Country:
Person performing phantom scans:
Tel:
Fax:
Postal Code:
Degree(s):
Email:
Person performing scanner QC:
Email:
Number of fixed PET/CT scanners available for ONCOLOGY Research:
Provide information below - use additional sheets as necessary for more than three stationery PET/CT units
A. SCANNER: Make/Model:
#CT Slices:
Year Manufactured:
Crystal Type:
Year Upgraded:
Mode for Oncology:
2D
Scanner Certification:
DOSE CALIBRATOR:
3D
None
Other Capabilities:
ACR
Capintec
Dose Calibrator Model:
Type of Upgrade:
ACRIN
Atomlab
B. SCANNER: Make/Model:
2D
3D
None
Dose Calibrator Model:
ACRIN
Atomlab
ToF
Cardiac Gating
CQIE
Veenstra
THIS IS THE:
#CT Slices:
Year Manufactured:
ICANL
Respiratory Gating
Other
Other
2D
3D
None
original F-18 setting OR
Type of Upgrade:
Other Capabilities:
ACR
Capintec
adjusted F-18 setting
Crystal Type:
Year Upgraded:
Dose Calibrator Model:
ACRIN
Atomlab
ToF
Cardiac Gating
CQIE
Veenstra
ICANL
Respiratory Gating
Other
Other
Year dose calibrator was installed:
Current F-18 # on your dose calibrator:
THIS IS THE:
original F-18 setting OR
Site able to: ~ transfer images electronically to a secure central server:
~ produce standard DICOM data sets:
Yes
No
~ employ a reconstruction matrix size of: 128 x 128
SOURCE FOR FDG
adjusted F-18 setting
Year dose calibrator was installed:
C. SCANNER: Make/Model:
DOSE CALIBRATOR:
Other
Type of Upgrade:
ACR
Current F-18 # on your dose calibrator:
Scanner Certification:
Other
original F-18 setting OR
Other Capabilities:
Capintec
Mode for Oncology:
ICANL
Respiratory Gating
Crystal Type:
Year Upgraded:
DOSE CALIBRATOR:
CQIE
Veenstra
THIS IS THE:
#CT Slices:
Year Manufactured:
Scanner Certification:
Cardiac Gating
Year dose calibrator was installed:
Current F-18 # on your dose calibrator:
Mode for Oncology:
ToF
Yes
Yes
adjusted F-18 setting
No // Burn CDs:
No // 256 x 256
Yes
Yes
No
No
Name / Location:
Regulatory Information: FDG provided under
PERSON COMPLETING FORM
Name:
Email:
NDA#: N
or
aNDA#:
Date:
Please fax or email this completed form to Jina Kim at jkim@snmmi.org / 703-667-5135 (fax)
Version 7/28/15_oncology
PET-CT Equipment Questionnaire