This questionnaire will help determine if your institution is credentialed to participate in a protocol. IROC Houston will notify you
and the study group of your status. The study group or IROC Houston will inform your institution when it can participate in the
requested protocol. If you have any questions, please contact IROC Houston at (713) 745-8989 or

Please note: You will be contacted via email or phone within 2 business days. Once we determine that all requirements are met, a credentialing letter will be issued within 5 business days.

Institution:   Study Group Name:
RTF#: (here) NCI #:
Name of person completing this form:    
  Phone #:   Email address:    
  Are you a:
Protocol to be credentialed:  
  Specify technique:  
Treatment planning system to be used for this protocol:  
Algorithm to be used for patient plans:  
Is your institution planning to use IGRT on this protocol, if applicable?
Has your institution successfully irradiated an IROC Houston phantom?
  If yes, which phantom?
  For SBRT(3D CRT/IMRT) treatments, what form of respiratory motion restriction / compensation
is used by your institution?
Has your institution completed IGRT credentialing for the protocol of interest?
Has your institution completed an IMRT or protocol-specific Benchmark?
Has your institution completed or updated the online IMRT or Proton Facility Questionnaire in the last 6 months?
Has your institution completed a SRS Questionnaire?
Has your institution completed a Motion Management Questionnaire?
Has your institution completed the protocol-specific Knowledge Assessment?
Does your institution have an account with TRIAD?