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 rpc@mdanderson.org

Institution: Study Group Name: RTOG GOG NCCTG SWOG CTSU ACCSOG ACRIN CALGB COG COMS ECOG NSABP Study Group #: RTF#: (here) NCI #: Name of person completing this form:     Email address: Phone #:   Are you a: Radiation Oncologist Physicist Dosimetrist Clinic Coordinator Protocol to be credentialed:     Specify technique: 3DCRT IMRT SBRT   Treatment planning system to be used for this protocol:   Algorithm to be used for patient plans:   Has your institution successfully irradiated an RPC phantom? Yes No   If yes, which phantom?    IMRT head & neck  IMRT pelvis lung stereotactic liver SRS head     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? Yes No Has your institution submitted the IMRT Facility Questionnaire to the ITC? Yes No Has your institution completed a SRS Questionnaire? Yes No Does your institution have an account with ITC? Yes No   If yes, has your institution successfully submitted data to ITC? Yes No Has your institution been credentialed for a protocol with similar requirements? Yes No   If yes, please list which protocol(s):