Name and address   of the hospital:                            Phone:                                    Fax:            Name of the Medical Physicist:                                     Phone:                                   Email:

1.

Make and model of Medical linear accelerator

2.

Photon energy  used for IMRT

6MV/15MV/18MV

3.

Make and model of MLC used  for IMRT

4.

Procedure adopted for QA of delivery system (machine specific QA). Describe the parameter,   test methods and tools used.) (please write in details , add separate page if needed)

5.

Make and model of the treatment planning system

6.

Procedure adopted for QA of treatment planning system used for IMRT/IGRT (TPS specific QA). Describe the parameter such dosimetric and non dosimetric parameters, test methods and tools used.(please write in details , add separate page if needed)

7.

Make and model of the imaging systems used for IMRT (e.g. CT-Sim, Sim-CT, PET-CT etc)

8.

Procedure adopted for Patient specific QA about: QA for setup verification

1. QA for set-up verification
2. Dosimetric QA

Describe the parameter, test methods and tools used.(please write in details , add separate page if needed)

9.

Is there any QA related to IMRT/IGRT carried out daily? if yes please describe it.

10.

Available QA tools, Make and models of dosimetry systems used in QA. ( Such as map checks, Imatrix, diode, MOSFET etc)

11.

Frequency of QA

1.TPS specific QA:

Daily/ weekly/ monthly/ others

2.Machine specific QA:

Daily/ weekly/Monthly/Others

3.Patient specific QA:

Daily/ weekly/Monthly/Others

12.

Sites and number of IMRT cases treated at your centre.

13.

 Margins for PTV in various cases such as  for H&N, Prostate, etc

14.

Criteria for accepting IMRT plan  (e.g. spatial agreement, dose agreement etc)

15.

Have you ever detected deviation larger than acceptable limit during the QA measurement? (if yes provide details)

16.

Are you satisfied with IMRT QA procedure?

17.

Major hurdle in performing IMRT QA

18.

Any suggestion for improving the IMRT QA procedure in Indian condition