Specialty Forms

Specialty Forms

ALARA Annual Review

NRC Part 20 and most state radiation safety regulations require an annual review of the center’s ALARA program. This audit form is designed to review the accelerator, CT simulation, and brachytherapy programs. The form may be used by licensees or registrants to self-assess the adequacy of their program, identify program weaknesses, and allow the center to take corrective actions (before an NRC or state inspection). The focus of the audit is directed at evaluating whether the center is maintaining exposures to staff and general public as low as is reasonably achievable (ALARA) and, if not, make suggestions for improvement. The form includes a review of the following areas: reviews of history, management commitment, and proposed users and uses; review of ALARA program (investigational occupational dose triggers); RSO annual and quarterly (minimum) reviews, educational responsibilities, ALARA deviations, investigational levels for occupational external doses, and review findings and corrective actions. The document file size is 5 pages. Document formatting uses Tables from Microsoft Word (doc).

$100

Quality Management Program (QMP) Annual Review

Most state radiation safety regulations require an annual review of the center’s quality management program. This audit form is designed to review the accelerator program. The form may be used by licensees or registrants to self-assess the adequacy of their program, identify program weaknesses, and allow the center to take corrective actions (before a state inspection). The focus of the audit is directed at evaluating whether the QMP is effective at minimizing patient treatment errors and regulatory infractions, and that activities are being conducted in a safe manner. The form includes a review of the following areas: audit history; organization and scope of program; radiation safety program; use by authorized individuals; amendments since last inspection; QMP training, retraining, and instructions; accelerator QMP training; facilities; audit of patient treatment charts/EMR; safety requirements; medical events; notifications and reports; bulletins and information notices; special license conditions or issues; and review findings and corrective actions. The document file size is 6 pages. Document formatting uses Tables from Microsoft Word (doc).

$150

Radiation Safety Program Annual Review

NRC Part 20 and most state radiation safety regulations require an annual review of the center’s radiation safety program. This audit form is designed to review the accelerator, CT simulation, and brachytherapy (manual) programs. The form may be used by licensees or registrants to self-assess the adequacy of their program, identify program weaknesses, and allow the center to take corrective actions (before an NRC or state inspection). The focus of the audit is directed at evaluating whether all activities are in compliance with regulatory requirements and the conditions of the license or registration, and that activities are being conducted in a safe manner. The form includes a review of the following areas: audit history; organization and scope of program; radiation safety program; use by authorized individuals; amendments; notifications; training, retraining, and instructions; facilities; dose measuring equipment; radiation protection and control of material; radiation survey instruments; public dose; patient release criteria; brachytherapy; radioactive waste (source disposal); receipt and transfer of material; transportation; accelerator servicing; AAPM TG-142 (non-IMRT, IMRT, SRS/SBRT): full calibration-accelerator, periodic spot checks for accelerator, and daily/weekly checks for accelerator; installation, maintenance, repair of accelerators; operating and emergency procedures for accelerators; personnel radiation protection; confirmatory measurements; medical events; notifications and reports; postings and labeling; bulletins and information notices; special license or registration conditions; and review findings and corrective actions. The document file size is 14 pages. Document formatting uses Tables from Microsoft Word (doc).

$200

Center Start-Up & Equipment List

This workbook consists of an in-depth list of center startup and equipment needs for a new radiation oncology center. The list is based on a typical radiation oncology center utilizing a multienergy linear accelerator, CT simulator, and MRI unit. Costs for each piece of equipment or item can be entered and totaled. The workbook consists of 11 active sheets: cover sheet, summary (costs), shielding, machines, physics equipment and related equipment, Therapist equipment, ancillary equipment, software, service agreements, physics equipment calibrations, and machine licenses. The last active sheet is a room-by-room checklist that lists all remaining items needed in a center. The workbook file size is 22 pages. Workbook formatting uses Microsoft Excel (xls).

$200

Mold Room OSHA Safety Program

This program is comprised of a procedure with forms and postings for mold room precautions and safety in a radiation oncology center. The potential hazards of working in a mold room where shielding blocks and cutouts are made consist primarily of inhalation of vapors and dust particles, ingestion of small fragments of metal, and skin penetrations. This program (Mold Room – Hazard Communication Standard and The Hazardous Chemical Right to Know Law (29 CFR 1910.1200)) addresses hazards associated with chemicals and certain metals in the mold room. The program complies with OSHA’s hazard communication standard and the hazardous chemical right to know law (29 CFR 1910.1200). The program includes the following features: policy statement; OSHA team; inventory worksheet; MSDS policy; labeling, tagging, or marking of containers; certification of personal protection equipment hazard assessment; written hazard communication program (29 CFR 1910.1200(e)); training of employees; mold room do’s and don’ts (posting); health hazards posting; required OSHA posting cover (29 CFR 1910.1025); lead blood test consent form; and sign-off sheets for reading/receipt/training in procedures and federal regulations. The document file size is 24 pages. Document formatting uses Microsoft Word (doc).

$300