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QA
Accelerator Daily Therapists Checks: Machine & Safety
This form is designed for recording linac safety and machine checks performed daily by the Therapists. On the front page, checks include ODI light accuracy, laser alignment, beam-on light, door interlock, audio and visual monitor, area monitor, and MLC pattern. On the back page, checks include machine water temperature, water level, water pressure, SF6 pressure, and air pressure. Specific laser adjustments can be recorded. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off weekly. Form formatting uses Microsoft Excel (xls).
$200
Accelerator Daily Therapists Checks: Output Constancy / F&S - Multienergy
This form is designed for recording linac output constancy and flatness & symmetry results for photons and electrons when using an array type device. Readings from five array positions (including the CAX) per energy and two EDWs can be manually recorded by the Therapist on a daily basis. Tolerance ranges are suggested. Form formatting uses Tables from Microsoft Word (doc).
$100
Accelerator Weekly Therapists Checks: Mechanicals & Safety
This form is designed for recording linac mechanical and safety checks performed weekly by the Therapists. Checks include gantry and collimator angle indicators, filed size indicator, ODI accuracy, cross-hair alignment, and emergency off switch. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off weekly. Form formatting uses Microsoft Excel (xls).
$100
Accelerator Monthly Therapists Checks: Backup MU
This form is designed for recording the linac backup MU readout performed monthly by the Therapists. A footnote describes how to perform the check with a recommended tolerance. The Physicist signs off monthly. Form formatting uses Microsoft Excel (xls).
$50
Accelerator Monthly Physics: Output and Energy Constancy - Multienergy
This form is designed for recording linac output and energy constancy measurements for photon and electron beams. Output and energy constancy is typically measured monthly by the Physicist. Footnotes include recommended tolerances. Form formatting uses Microsoft Excel (xls).
$100
Accelerator Monthly Physics Checks: Flatness and Symmetry - Data Collection and Analysis Sheet
This form is designed for recording linac flatness and symmetry for photon and electron beams. Using radiographic film and measuring optical density, flatness and symmetry is typically performed monthly by the Physicist. Footnotes describe how to perform the checks and calculate the results using recommended tolerances. Form formatting uses Tables from Microsoft Word (doc).
$100
Accelerator Monthly Physics Checks: Mechanical and Safety Checks
This form is designed for recording linac mechanical and safety checks performed monthly by Physics. Checks include gantry and collimator angle indicators (level vs digital vs mechanical); field size indicators (2 field sizes); ODI accuracy (3 distances); flatness and symmetry; light field vs radiation field (field size, CAX, congruence, and intensity); cross-hair alignment; door interlock; emergency off switch; asymmetric jaw indicators; wedge and electron cone interlocks; wedge, tray, and electron cone position; latching (wedge, cone, tray, and graticule); and treatment couch vertical and rotation. Footnotes describe how to perform the checks with recommended tolerances. A second Physicist (if available) signs off. Form formatting uses Microsoft Excel (xls).
$200
GE CT Simulator: Daily Therapists Checks
This form is designed for recording machine and safety checks for a GE LightSpeed series CT simulator. These checks are typically performed daily by the Therapists. On the front page, daily checks include contrast scale, high contrast resolution, slice thickness, low contrast delectability and noise/uniformity. On the back page, daily checks include beam-on light, audio monitor, lasers (x, y, and z), and monthly emergency off. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off monthly. Form formatting uses Microsoft Excel (xls).
$200
Oldelft Conventional Simulator: Daily Therapists Checks
This form is designed for recording Oldelft conventional simulator machine and safety checks performed daily by the Therapists. On the front page, daily checks include ODI light accuracy, laser alignment, and beam-on light. On the back page, laser adjustments are recorded. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off weekly. Form formatting uses Microsoft Excel (xls).
$100
Oldelft Conventional Simulator: Weekly Therapists Checks
This form is designed for recording conventional simulator mechanical and safety checks performed weekly by the Therapists. Checks include gantry and collimator angle indicators, filed size indicator, ODI accuracy, cross-hair alignment, and emergency off switch. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off weekly. Form formatting uses Microsoft Excel (xls).
$100
Oldelft Conventional Simulator: Monthly Physics Checks
This form is designed for recording conventional simulator mechanical and safety checks performed monthly by Physics. Checks include gantry and collimator angle indicators (level vs digital vs mechanical), field size indicators (2 field sizes), ODI accuracy (3 distances), fluoroscopic image resolution test, light field vs radiation field (field size, CAX, congruence, intensity), cross-hair alignment, interlocks (door and touch guard), emergency off switch, and asymmetric jaw indicators. Footnotes describe how to perform the checks with recommended tolerances. A second Physicist (if available) signs off. Form formatting uses Microsoft Excel (xls).
$100
Diacor CT Simulator Motorized Laser System Checks
This form is designed for recording Diacor motorized laser system checks for a CT simulator. These checks are typically performed monthly by the Therapists or Physicist. On the front page, monthly checks include x, y, and z arms and CT zero. On the back page, laser adjustments are recorded. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off monthly or after laser adjustments. Form formatting uses Microsoft Excel (xls).
$200
Gammex CT Simulator Motorized Laser System Checks
This form is designed for recording Gammex motorized laser system checks for a CT simulator. These checks are typically performed monthly by the Therapists or Physicist. On the front page, monthly checks include x, y, and z arms and CT zero. On the back page, laser adjustments are recorded. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off monthly or after laser adjustments. Form formatting uses Microsoft Excel (xls).
$200
Heustis Block Cutter: Monthly Therapists Checks
This form is designed for recording Heustis block cutting machine checks performed monthly by the Therapists. Checks include illuminator intensity/uniformity, block cutter geometry, cutting wire temperature, light position verification, and overall system. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off monthly. Form formatting uses Microsoft Excel (xls).
$100
The Clark® Auto-Indexing Precision Block Cutter: Monthly Therapists Checks
This form is designed for recording Clark® block cutting machine checks performed monthly by the Therapists. Checks include illuminator intensity/uniformity, perpendicularity, cutter try orientation, upper arm alignment, harp upper rod checks, lower rod checks, tracking, projection, and overall system. Footnotes describe how to perform the checks with recommended tolerances. The Physicist signs off monthly. Form formatting uses Microsoft Excel (xls).
$100
Film Processor: OD Data Collection
This form is designed for recording film processor optical density (OD) measurements. The form automatically calculates average OD values from various optical density steps (#10, 13, 14, and 21) and the contrast index range. Tolerance ranges are automatically calculated and serve as a baseline for future, daily OD measurements. Footnotes describe how to perform the film-based OD measurements with recommended tolerances. The Physicist signs off weekly. Form formatting uses Microsoft Excel (xls).
$100
Film Cassettes: Monthly Therapists Checks
This form is designed for recording film cassette and screen checks performed monthly by the Therapists. The Physicist signs off monthly. Form formatting uses Microsoft Excel (xls).
$50
Quality Management
Diode Point Measurement Dosimetry
This form is designed for recording patient diode measurements performed by the Therapists. For each patient, the form includes the following information: site of measurement, field number, MU setting, SSD, energy, predicted vs measured diode reading, percent difference, and Physicist/Physician approval. Form formatting uses Tables from Microsoft Word (doc).
$50
EMR / Chart QA Checklist
This form is designed for recording and tracking various checks and QA performed by the Physician, Physics, Therapists, and Nursing. For each patient, the form includes a number of checks: Physician – consultation Note/OTV, diagnosis and staging, consent form verified, CT simulation instructions, R&V Rx approved, and treatment plan/calculation approved (plan approved); Physics – calculation, calculation check, R&V Rx verified and approved, R&V treatment fields verified, calculation checks timely, and physics weekly chart check; Therapists – ID and field photos, patient set-up/parameters, isocenter shifts verified, physics calculation check, diodes, images, and therapists weekly chart check; Nursing – Insurance info/face photo, HIPAA form signed, surgery/pathology reports, H&P, nursing assessment/notes, consent form/witness, and x-rays/CT/MRI/PET/lab work. Form formatting uses Microsoft Excel (xls).
$200
Physics Weekly Chart Check
This form is designed for recording weekly chart checks performed by the Physicist. For each patient, the form includes the following key check-offs: routine vs different reviewer, treatment status, days since last check, prescription (energy, wedge, MLC, and bolus), simulation instructions, independent dose calc and treatment parameters check (Therapists and Physicist), treatment plan and calculations review/approval (MD signature), diodes, daily and cumulative doses, and final chart check (prescribed dose delivered and treatment summary). Form formatting uses Tables from Microsoft Word (doc).
$200
Therapists Weekly Chart Check
This form is designed for recording weekly chart checks performed by the Therapists. For each patient, the form includes the following key check-offs: routine vs different reviewer, treatment status, days since last check, prescription (energy, wedge, MLC, and bolus), simulation instructions, independent dose calc and treatment parameters check (Therapists and Physicist), treatment plan and calculations review/approval (MD signature), diodes, daily and cumulative doses, and final chart check (prescribed dose delivered and treatment summary). Form formatting uses Tables from Microsoft Word (doc).
$200
Weekly Status Report: Physics / QA Program
This form is designed for auditing the timely completion of various QA checks routinely performed by either Physics staff or the Therapists. This form also serves as a self-audit tool to help the Physicist demonstrate compliance with ongoing reviews required by various state quality management and radiation safety programs. For Physics, the form includes checks of the following: daily calc checks, weekly chart checks, various monthly accelerator checks, monthly treatment planning computer checksum verifications, monthly CT sim checks, and monthly CT sim motorized laser checks. For Therapists, the form includes checks of the following: various daily, weekly, and monthly accelerator checks; various daily CT sim checks; and monthly accelerator and CT sim fault log checks. Form formatting uses Microsoft Excel (xls).
$100
Error Reduction (paper-based)
Pre-Treatment & Post-Treatment Unintended Deviations with Reporting
(includes step-by-step procedure)
This program is comprised of three sections and a step-by-step procedure. All three sections are designed for recording and correcting errors identified in the patient treatment process. Failures in quality assurance and radiation safety processes can also be identified and corrected. The procedure describes the process of error reduction with details on how to identify, categorize, evaluate, correct, and record errors. Errors are categorized as occurring either before and after the patient is treated with radiation. The first section (Pre-Treatment Unintended Deviations Form) and second section (Post-Treatment Unintended Deviations Form) each consist of a detailed, two page grid showing monitored categories, subcategories, and attributes. Attributes are defined as brief, descriptive examples of various, possible unintended deviations (errors) that could be encountered in a particular clinical, QA, QMP, or radiation safety process. Responsible parties are assigned to each monitored attribute and are generally accountable for the correct performance of that attribute’s task. When an error is identified, it is recorded by “checking off” the box associated with that attribute. The responsible and affected individual(s) then proceed with formulating an action plan to correct the error. Levels of significance are assigned to each error and range between 1 (most severe) and 5 (least severe). Errors that rise to the severity level (SL) of 1 or 2 (e.g., near misses, instances where a key failure in the patient treatment process results in a deterministic, measurable effect on the patient; medical event (misadministration); or violation of a state or federal requirement) escalate to a higher significance and are recorded in the third section (Unintended Deviation Reporting Form). The Unintended Deviations Reporting Form requires a description, evaluation, and assessment of the error including immediate and long-term corrective action(s). The last step is submission of this form to the reviewer (i.e., radiation oncology physicist or radiation safety officer) for their evaluation and recommendations for action. The final disposition of all sections and data resides with the Quality Improvement Committee or equivalent. The document file size is 12 pages. Form and procedure formatting uses Microsoft Word and Tables (doc).
$500
Pre-Treatment Quarterly Unintended Deviation Summary
This form comprises a summary report of all pre-treatment unintended deviations tabulated on a quarterly frequency. The form is designed to be used in conjunction with the program Pre-Treatment and Post-Treatment Unintended Deviations with Reporting (includes step-by-step procedure). The summary report shows all monitored categories listed on the Pre-Treatment Unintended Deviations Form. Frequency of error by significance level and key process can be entered into the table for quarterly review by the Quality Improvement Committee or equivalent. This Form formatting uses Tables from Microsoft Word (doc).
$100
Post-Treatment Quarterly Unintended Deviations Summary
This form comprises a summary report of all post-treatment unintended deviations tabulated on a quarterly frequency. The form is designed to be used in conjunction with the program Pre-Treatment and Post-Treatment Unintended Deviations with Reporting (includes step-by-step procedure). The summary report shows all monitored categories listed on the Post-Treatment Unintended Deviations Form. Frequency of error by significance level and key process can be entered into the table for quarterly review by the Quality Improvement Committee or equivalent. Form formatting uses Tables from Microsoft Word (doc).
$100
Unintended Deviation Tracking
This form is designed to track each unintended deviation through the review and approval process. Each error is tracked based on the following timeline: date the UD is sent to Physicist/RSO, date UD is received back from Physicist/RSO, date UD is received by the Quality Improvement Committee or equivalent, and date the UD is filed. Copies of all reviewed and approved UDs are attached to this form and filed each calendar quarter. Form formatting uses Tables from Microsoft Word (doc).
$50
Radiation Safety
Accelerator: Operating Procedures (state required posting)
This form serves to meet state radiation safety requirements for linac postings. Specifically, most states require posting of operating procedures at the console area of the linear accelerator. This form lists operating and safety requirements (one page) that must be followed by all staff and physicians when treating patients. Form formatting uses Microsoft Word (doc).
$100
Accelerator: Emergency Procedures (state required posting)
This form serves to meet state radiation safety requirements for linac postings. Specifically, most states require posting of emergency procedures at the console area of the linear accelerator. This form lists emergency requirements (one page) that must be followed by all staff and physicians when treating patients. Form formatting uses Microsoft Word (doc).
$100
CT Simulator: Operating Procedures (state required posting)
This form serves to meet state radiation safety requirements for CT simulator postings. Specifically, most states require posting of operating procedures at the console area of the CT simulator. This form lists operating and safety requirements (one page) that must be followed by all staff and physicians when simulating patients. Form formatting uses Microsoft Word (doc).
$100
CT Simulator: Emergency Procedures (state required posting)
This form serves to meet state radiation safety requirements for CT simulator postings. Specifically, most states require posting of emergency procedures at the console area of the CT simulator. This form lists emergency requirements (one page) that must be followed by all staff and physicians when simulating patients. Form formatting uses Microsoft Word (doc).
$100
Door Interlock Bypass Authorization for Accelerator
This form is designed to comply with state regulations that address bypassing certain interlocks on accelerators and the associated radiation safety precautions. The form describes the necessity of a qualified service engineer to intentionally bypass door interlock switches located on the shield door of the linac treatment room. Approval is documented by the Radiation Safety Officer under certain conditions and precautions. Form formatting uses Microsoft Word (doc).
$100
Employee Declaration of Pregnancy and Training
This form is designed to meet NRC and state regulations that address employee declaration of pregnancy and required training. The form (one page) includes two sections: (1) declaration of pregnancy - definition of declared pregnant woman, estimated date of conception, issuance of fetal radiation monitoring device, radiation dose limits, training on exposure, and issuance of pertinent NRC guidance; and (2) acknowledgement of radiation safety training, receipt of NRC guidance, and receipt of declaration form. Form formatting uses Microsoft Word (doc).
$100
Physicist / RSO Requirements Checklist
This form is a one page checklist for use by the Physicist/Radiation Safety Officer (RSO) to help ensure timely performance of routine QA and radiation safety duties. Various tasks, typically required in a radiation oncology clinic that utilizes a multi-energy accelerator and CT simulator, are listed with their required frequency. Footnotes list helpful details to complete the tasks. Form formatting uses Tables from Microsoft Word (doc).
$100
Machines
Accelerator: Fault Log
This form is designed to record faults that occur when operating an accelerator. The form (one page can record 13 separate events) includes the following information: date, time, initials, console fault/interlock, description of problem, when problem occurred (morning warm-up, programming, clinical, “beam on”), parameters (mode, gantry angle, MUs), number of patients not treated, downtime, service notification (date and time), problem fixed (date, time, and description of fix), and Physics check. Form formatting uses Microsoft Excel (xls).
$100
CT Simulator: Fault Log
This form is designed to record faults that occur when operating a CT simulator. The form (one page can record 11 separate events) includes the following information: date, time, initials, fault code/interlock, description of problem, when problem occurred (tube warm-up, calibration, scan, and reconstruction), parameters (kVp and mA), number of patients not simulated, downtime, service notification (date and time), problem fixed (date, time, and description of fix), and Physics check. Form formatting uses Microsoft Excel (xls).
$100
Varian Accelerator iX: Interlock Clearance Guide
This form is designed to show interlock codes from a Varian iX accelerator with suggested individuals who are allowed to “clear” specific interlocks. The form is a table (one page) listing 68 interlock codes. The types of interlocks are categorized as minor, major, or dosimetry. Levels of approval are Therapists, Engineers/Physics, and Physics. NOTE: Suggested authorized individuals allowed to “clear” various interlocks are not based on any recommendations of Varian Medical Systems. The Form formatting uses Microsoft Excel (xls).
$100
Equipment / Instrumentation
Barometer and Thermometer Intercomparison
This form is designed for recording periodic barometer and thermometer intercomparison results. A 96-hour time window is allowed for intercomparison of the measuring devices. Readings are recorded on the form. Tolerances and frequencies of testing are established. Form formatting uses Tables from Microsoft Word (doc).
$100
Radiation Area Monitor Operational Check
This form is designed to comply with certain state regulations that require radiation area monitors (used at the entrance of a linac vault) be calibrated at intervals not to exceed 12 months. Most states define calibration as equivalent to operational check. In these cases, this check can be performed by the licensee or registrant using a radioactive check source (e.g., 10 µCi cesium-137). The form describes the operational check procedure and records the checks. Form formatting uses Microsoft Word (doc).
$100
Clinical
CT Simulation Instruction Worksheet
This form is a worksheet designed for specifying simulation instructions. Various directives and details of the simulation procedure can be “checked-off” using a checklist and short narrative format. The form includes the following fields: patient information, anatomical site, simulation procedure, type of treatment plan, consent verification, key prescription elements, patient position, head position, treatment aids/devices, landmark wire, contrast, special instructions, and other precautions. An anatomical diagram of the body allows the physician to indicate the scan volume, and approximate port edge and isocenter locations. Form formatting uses Microsoft Word (doc).
$100
Dose Calculations
Monitor Unit Calculations: Photons - Isocentric (SAD) Setup
This form is a worksheet designed to manually calculate monitor units (MUs) for photon beams. The one page worksheet calculates MUs for up to four treatments fields. For SAD setups conditions, the following information is input to calculate MUs for each treatment field: General information (patient name and number, physician, and date); treatment field information (field name and number, machine and serial number); prescription specifics (energy, total dose/fraction, dose/field, and Rx isodose line); collimator and blocked equivalent square; collimator and phantom scatter factors; tracy factor; SSD; calc depth; TMR; inverse square law; inverse square off-axis calc point; wedge factor (fixed or dynamic); off-axis wedge factors (gradient and non-directions); and off-axis open field factor. The worksheet shows the formula used to calculate MUs for each field. The percent difference between the hand and computer calculations is determined. The individuals who performed and checked the calculation are shown. Worksheet formatting uses Microsoft Excel (xls).
$200
MU Calcs: Photons (SAD) - Step-By-Step Procedure
This optional procedure is designed to be used with the above worksheet Monitor Unit Calculations: Photons - Isocentric (SAD) Setup. The four page procedure shows how to completed the worksheet in a step-by-step fashion. Procedure formatting uses Microsoft Word (doc).
$100
Monitor Unit Calculations: Photons SSD Setup
This form is a worksheet designed to manually calculate monitor units (MUs) for photon beams. The one page worksheet calculates MUs for up to four treatments fields. For SSD setups conditions, the following information is input to calculate MUs for each treatment field: General information (patient name and number, physician, and date); treatment field information (field name and number, machine and serial number); prescription specifics (energy, total dose/fraction, dose/field, and Rx isodose line); collimator and blocked equivalent square; collimator and phantom scatter factors; tracy factor; SSD, calc depth; PDD; wedge factor (fixed or dynamic); off-axis wedge factors (gradient and non-directions); off-axis open field factor; and extended SSD correction factor (new vs standard SSD and inverse square correction factor formula). The worksheet shows the formula used to calculate MUs for each field. The percent difference between the hand and computer calculations is determined. The individuals who performed and checked the calculation are recorded. Worksheet formatting uses Microsoft Excel (xls).
$200
MU Calcs: Photons (SSD) - Step-By-Step Procedure
This optional procedure is designed to be used with the above worksheet Monitor Unit Calculations: Photons SSD Setup. The four page procedure shows how to completed the worksheet in a step-by-step fashion. Procedure formatting uses Microsoft Word (doc).
$100
Diode Dose Calculations & Patient Diode Measurements: Photons
This form is a worksheet for diode dose calculations and patient diode measurements using photons. The worksheet (one page) is comprised of two sections. The first section uses the following information to manually calculate dose to the diode: general information (patient name and number, physician, and date); treatment field information (field name and number, machine and serial number); treatment specifics (energy, total dose/fraction, dose /field, and Rx isodose line); SSD to diode; diode field size correction factor; diode SSD correction factor; and other applicable correction factors (diode off-axis correction factor, diode wedge factor, and diode wedge off-axis correction factor). The dose to the diode is recorded. A range of acceptability is established. The individuals who performed and checked the calculation are also recorded. The second section comprises the patient diode measurements. For each field, diode readings are recorded. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates the worksheet. Worksheet formatting uses Microsoft Excel (xls).
$100
Monitor Unit Calculations: Photons - SSD Changes
This form is a worksheet designed to manually calculate monitor unit (MU) changes resulting from SSD changes for photon fields. The one page worksheet accommodates MU changes for up to four treatments fields. For each field, the previous and new SSD is recorded. The corresponding previous and new tissue phantom ratios (TPRs) are recorded. A workspace is provided to ratio the TPRs and calculate the new MUs per field. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates the worksheet. Worksheet formatting uses Microsoft Excel (xls).
$100
Monitor Unit Calculations: Photons - Dose Change in Rx
This form is a worksheet designed to manually calculate dose changes resulting from prescription changes for photon fields. The one page worksheet accommodates dose and corresponding MU changes per field for up to four treatments fields. For each field, the previous and new prescription dose per fraction is recorded. A correction factor is derived using a workspace with equations to calculate the new dose and MU for each field. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates the worksheet. Worksheet formatting uses Microsoft Excel (xls).
$100
Monitor Unit Calculations: Electrons
This form is a worksheet designed to manually calculate monitor units (MUs) for electron beams. The one page worksheet calculates MUs for the treatments field. The following information is input to calculate MUs: General information (patient name and number, physician, and date); treatment field information (field name and number, machine and serial number); prescription specifics (energy, total dose/fraction, depth, and Rx isodose line); cone size; open cone/measured output factor; bolus; SSD; and relative output factor at extended distance. The worksheet shows the formula used to calculate MUs. The individuals who performed and checked the calculation are recorded. Worksheet formatting uses Microsoft Excel (xls).
$200
MU Calcs: Electrons - Step-By-Step Procedure
This optional procedure is designed to be used with the above worksheet Monitor Unit Calculations: Electrons. The three page procedure shows how to completed the worksheet in a step-by-step fashion. Procedure formatting uses Microsoft Word (doc).
$100
Monitor Unit Calculations: Electrons With Diode Dose Calculations & Patient Diode Measurements
This form is a worksheet for electron measurements and calculations. The worksheet (one page) is comprised of three sections. The worksheet is designed to: (1) calculate monitor units, (2) calculate diode dose, and (3) record patient diode measurements. For section 1, the following information is input to manually calculate MUs: general information (patient name and number, physician, and date); treatment field information (field name and number, machine and serial number); prescription specifics (energy, total dose/fraction, depth, and Rx isodose line); cone size; open cone/measured output factor; bolus; SSD; and relative output factor at extended distance. For section 2, the diode dose calculation requires a field size dependence diode correction factor, SSD diode correction factor, dose to diode expected reading, and diode range of acceptability. For section 3, patient diode measurements are recorded. The individuals who performed and checked the calculation are also recorded. The worksheet shows the formulas used to calculate MUs and dose to diode. Worksheet formatting uses Microsoft Excel (xls).
$100
Monitor Unit Calculations: Electron Cutout Measurements
This form is a worksheet for electron cutout measurements and calculations. A brief procedure describes the processes. The worksheet is designed to manually calculate monitor units from electron cutout measurements. The worksheet (one page) is comprised of the following information: general information (patient name and number, physician, and date); treatment field parameters (field name and number); prescription specifics (energy, prescribed dose, depth, and Rx isodose line); cone size; bolus; SSD; and dmax. Measurements from the open vs cutout fields are recorded. MUs are calculated using a formula. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates this worksheet. Worksheet formatting uses Microsoft Excel (xls).
$100
Monitor Unit Calculations: Electron Cutout Measurements With Diode Measurements & Patient Diode Measurements
This form is a worksheet for electron cutout calculations and measurements. A brief procedure described the processes. The worksheet is designed to: (1) manually calculate monitor units (MUs), (2) manually calculate diode dose, and (3) record patient diode measurements. The worksheet (one page) is comprised of three sections. For section 1, the following information is input: general information (patient name and number, physician, and date); treatment field parameters (field name and number); prescription specifics (energy, prescribed dose, depth, and Rx isodose line); cone size; bolus; SSD; and dmax. Readings from the open field vs cutout field measurements are recorded. MUs are calculated using a formula. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates this section. For section 2, diode measurements are recorded and a diode range of acceptability is established. For section 3, patient diode measurements are recorded. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates this section. Worksheet formatting uses Microsoft Excel (xls).
$100
Cord Dose: Summary
This form is a worksheet designed to track spinal cord dose. The one page worksheet contains the following information: general information (patient name and number, physician, and date), fields, cord dose/fraction, number of fractions, total cord dose, cumulative cord dose, and physician initials. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates this section. Worksheet formatting uses Microsoft Excel (xls).
$50
Gap Calculation: Photons
This form is a worksheet designed to manually calculate the skin gap required to prevent overlap of abutting photon treatment fields at depth. The one page worksheet contains general information (patient name and number, physician, and date) and gap parameters. For both fields, the gap parameters include the following information: field length or width at isocenter, distance where field size is specified, and depth of gap calculation as prescribed by the physician. A gap equation and workspace is provided for calculating the total skin gap. A sagittal view of the body is provided with both adjacent radiation fields and components labeled. The individuals who performed and checked the calculation are recorded. The requesting physician also signs and dates the worksheet. Worksheet formatting uses Microsoft Excel (xls).
$100
Mantle Field: Patient Setup Check on Accelerator
This form is a worksheet designed to record calculation information for a mantle field setup on an accelerator. The one page worksheet contains general information (patient name and number, physician, and date) and setup information. From twelve preselected points designated on an anatomical diagram (covering from the neck to the lower mediastinum), the corresponding SSDs and separations can be measured and the depths determined for calculating dose to these points. The individual who performed the measurements is recorded. Worksheet formatting uses Microsoft Excel (xls).
$100
Mantle Field: Point Dose Summary
This form is a worksheet designed to track dose on a mantle field. The one page worksheet contains general information (patient name and number, physician, and date) and setup information. From twelve preselected points designated on an anatomical diagram (covering from the neck to the lower mediastinum), the AP and PA contributing dose, total dose, and percent of total dose can be summarized. The individuals who performed and checked the dose tracking are recorded. The requesting physician also signs and dates this worksheet. Worksheet formatting uses Microsoft Excel (xls).
$100
FREE
NRC Part 19 / State Equivalent Posting
(NRC and state required posting)
This form serves to comply with NRC Part 19 and state radiation safety regulations for postings of certain documents. Specifically, the NRC and all states require licensees or registrants to post current copies of documents, such as certain regulations, the license or certificate of registration, conditions or documents incorporated into the license by reference and amendments, etc. These documents must be posted conspicuously and in an adequate number of locations. If posting of these documents is not practicable, this one page notice may be posted and comply with these regulations. Form formatting uses Microsoft Word (doc).
FREE
Physics Calc Check Fax Transmittal
This form is designed for faxing physics calculations for second checks on multiple patients. The form includes the patient’s name and the following information in a “check-off” format: Sender (Rx in chart and R&V, Tx parameters, sim setup sheet, outline of blocked fields, manual calc checks, signed isodose distribution, and start date) and Recipient (all faxed sheets checked and comments). Worksheet formatting uses Microsoft Excel (xls).
FREE
Dosimetry Sign-In Sheet
This form is designed to serve as a dosimetry sign-in sheet for tracking the status of multiple patient calculations. The form includes the following information in a “fill in the blank” and “check-off” format: patient name, start date and time, treatment field names, MLC or blocks, calcs/input done, calcs/input checked, and billed. Worksheet formatting uses Microsoft Excel (xls).
FREE
CT Simulation Record
This form is a worksheet designed for specifying CT simulation instructions. Various details of the simulation procedure can be “checked-off” or described in a brief narrative. The form includes the following information: patient information, anatomical site, patient position, immobilization (Alpha Cradle, Aquaplast), head device, bite block, prone pillow, breast board, arm position, feet position, and special setup devices. Worksheet formatting uses Microsoft Excel (xls).
FREE
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