CREDENTIALING FOR ADVANCED TECHNOLOGY PROTOCOLS
This questionnaire will help determine if your institution is credentialed to participate in a protocol. The RPC will notify you and the study group of your status. RTOG or the RPC will inform your institution when it can participate in the requested protocol. If you have any questions, please contact the RPC at (713) 745-8989 or
Study Group Name:
Study Group #:
Name of person completing this form:
Are you a:
Protocol to be credentialed:
Treatment planning system to be used for this protocol:
Algorithm to be used for patient plans:
Has your institution successfully irradiated an RPC phantom?
If yes, which phantom?
IMRT head & neck
For SBRT(3D CRT/IMRT) treatments, what form of respiratory motion restriction / compensation
is used by your institution?
Has your institution completed an IMRT Benchmark?
Has your institution submitted the IMRT Facility Questionnaire to the ITC?
Has your institution completed a SRS Questionnaire?
Does your institution have an account with ITC?
If yes, has your institution successfully submitted data to ITC?
Has your institution been credentialed for a protocol with similar requirements?
If yes, please list which protocol(s):