IAC Echocardiography Fetal
Add-on Supplemental Form
An additional testing area (or areas) may be added to a facility’s current accreditation at any time during the threeyear accreditation cycle. Accreditation is granted only for the specific testing areas for which a facility has applied
and submitted an application. Though facilities may be performing other testing in the facility, those areas are not
covered under the accreditation until an application for the specific testing type is submitted and granted
accreditation. The following form is to be used for supplemental testing only. If your facility is not currently
accredited in echocardiography please contact the IAC.
Please answer all questions, required attachments will be indicated by the  symbol. Case studies requirements are
listed on page two.
Name of institution (as listed in the IAC Accreditation Agreement):
(This institution name will be tracked in the IAC database and will receive all IAC correspondence)
Department:
Street Address 1:
Street Address 2:
City:
State:
Zip code:
Location of Echocardiography facility:
Hospital (number of beds:
Private Office
Freestanding imaging center
Independent facility
Other (specify):
)
1) Enter the total number of procedures performed in the facility (or facilities) annually by type of examination
(this includes all sites and mobile locations):
Fetal Echocardiography:
2) Does the Medical Director interpret fetal echocardiography exams in this facility?
Yes
No
3) Enter the average annual volume of fetal studies interpreted by the Medical Director in this facility
(Applicable Standard: Part 3.3B):
IAC Echocardiography Fetal Add-On Supplemental Form
Reviewed 11/2014
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4) Please list the medical and technical staff that performs or interprets fetal studies and their annual volumes:
Interpreting Physician
Fetal Volumes
Enter how many minutes are allotted for each of the following echocardiogram procedures from patient encounter to
patient departure in the facility (Applicable Standard: 3.5.2B):
Initial complete fetal echocardiogram:
Follow-up or repeat fetal echocardiogram:
 Submit a copy of the facility-specific, step-by-step fetal echocardiography protocol.
IMPORTANT: The staff count you enter on this page is used to determine the overall number of fetal
echocardiography case studies you will be required to provide.
To review how the value you enter impacts the number of required case studies, refer to the following instructions
for fetal echocardiography case studies.
Enter the number of medical and technical staff members you have interpreting/performing Fetal Echocardiography
exams:
FETAL ECHOCARDIOGRAPHY CASE STUDIES:



The required fetal case studies are based on the total number of staff (medical and technical) in an applicant
facility. Following are the required number of fetal case studies per facility:
o 5 or fewer = 4 cases per facility (1 shunt, 1 simple obstruction, 1 case with an indication or finding
of fetal arrhythmia and 1 case of hypoplastic ventricle)
o 6 to 8 staff = 6 cases per facility (2 shunts, 2 simple obstructions, 1 case with indication or finding
of fetal arrhythmia and 1 case of hypoplastic ventricle)
o 9 to 15 staff = 8 cases per facility (4 shunts, 2 simple obstructions, 1 case with an indication or
finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
o 16 to 25 staff = 10 cases per facility (4 shunts, 3 simple obstructions, 1 complex defect, 1 case
with an indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
o >25 staff = 12 cases per facility (4 shunts, 4 simple obstructions, 2 complex defects, 1 case with an
indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
Cases submitted with the application must not be independently performed by sonographer or physician
trainees.
All cases must be selected from within the past 12 months from the date of application filing.
IAC Echocardiography Fetal Add-On Supplemental Form
Reviewed 11/2014
2