New/Addition Staff and

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New/Addition Staff and

  1. 1. Included in this form are: 1. Forms for new medical directors and technical directors 2. Forms for medical staff and technical staff background, experience, training and CME/CE 3. Instrumentation forms If you have more staff or instrumentation than will fit on these forms, you should do a “save as” of this document as many times as necessary to accommodate as many entries as you need. Version 3.0 ICANL Accreditation Application Extra Forms
  2. 2. Overview Of Medical Director And Interpreting Medical Staff Complete the following tables. Use the legend below to designate specialty. List all members of the interpreting medical staff, including the Medical Director(s). This page may be photocopied if more space is required. Total number of Interpreting Medical Staff (including Medical Director)       Medical Staff Primary Check if Average annual volume Average annual volume (including Medical Specialty authorized of studies interpreted in of studies interpreted in Director) user this laboratory other laboratories                                                                                                                                                                                                                                                 Legend: Primary specialty: (C) = cardiology; (R) = radiology; (NM) = nuclear medicine; (O) = Other (specify) Overview of Technical Director and nuclear medicine technologists Complete the following tables. Use the legend below to designate personnel credentials. List all nuclear medicine technologists, including the Technical Director(s). This page may be photocopied if more space is required. Total number of Technical Staff (including Technical Director)       Technical Staff (including Credential Approximate annual volume Approximate annual Technical Director) of studies performed in this volume of studies laboratory by person listed performed in other laboratories                                                                                                                                                                                                                                                 Legend: Credential(s) - List all that apply: (CNMT) = Certified Nuclear Medicine Technologist. RT(N) = Radiologist Technologist (Nuclear); (NCT) = Nuclear Cardiology Technologist; (PET) = PET Technologist; (O) = Other (specify) Version 3.0 ICANL Accreditation Application Extra Forms
  3. 3. Medical Director All questions must be answered. Do not submit a curriculum vitae.) Name:       MD DO E-mail:       • Physician Licensure: State(s):       Expiration Date(s):        Enclose a copy of current medical license(s) for geographical areas related to this application. • Authorized user under NRC/state radioactive material license yes no if no please explain      Education And Training Information (do not include curriculum vitae) • Medical education: Medical School:       Year MD/DO degree:       • Residency training: Institution:       Location:       Specialty:       Dates: from      to       Number of months dedicated to nuclear cardiology:       • Fellowship training: Institution:       Location:       Specialty:       Dates: from      to       Number of months dedicated to nuclear cardiology:       Training And Experience Of The Medical Director Nuclear Cardiology: • Check at least one Certification in nuclear cardiology by the Certification Board of Nuclear Cardiology (CBNC). Board certified (or Board eligible but within two years of finishing training in Cardiology) and completion of a minimum of a 4 month formal (Level 2 1995 ACC/ASNC COCATS Training Guidelines) training program in nuclear cardiology. This requirement applies only to cardiologists who began their cardiology training in July 1995 or later. Board certified in cardiology and training equivalent to Level 2 training, or at least one year of nuclear cardiology practice experience with independent interpretation of at least 600 nuclear cardiology studies. This requirement applies only to cardiologists who began their cardiology training before July 1995. Board certified (or Board eligible but within two years of finishing training) in Nuclear Medicine Board certified (or Board eligible but within two years of finishing training) in Radiology with at least 4 months of nuclear cardiology training. Board certified (or Board eligible but within two years of finishing training) in radiology and at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 600 nuclear cardiology studies. Version 3.0 ICANL Accreditation Application Extra Forms
  4. 4. Board certified (or Board eligible but within two years of finishing training) in any other medical specialty recognized by the American Board of Medical Specialties or American Osteopathic Association and at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 600 nuclear cardiology studies. Ten years of nuclear cardiology practice experience with interpretation of at least 600 nuclear cardiology examinations. Nuclear medicine and/or PET: • Check at least one Board certified (or Board eligible but within two years of finishing training) in nuclear medicine. Board certified (or Board eligible but within two years of finishing training) in radiology with special competence in nuclear medicine. Board certified (or Board eligible but within two years of finishing training) in radiology with at least 4 months of nuclear medicine training with interpretation of at least 800 nuclear medicine procedures. Board certified (or Board eligible but within two years of finishing training) in any other medical specialty recognized by the American Board of Medical Specialties (ABMS) or American Osteopathic Association and at least one year (full time equivalent) of nuclear medicine practice experience with independent interpretation of at least 1000 general nuclear medicine procedures and/or, if performing nuclear medicine therapies, independent performance of a least 20 nuclear medicine therapies. Ten years of nuclear medicine practice experience with independent interpretation of at least 1000 general nuclear medicine procedures and/or, if performing therapies, independent performance of at least 20 nuclear medicine therapies.  Provide copies of appropriate documentation such as:  CBNC certificate or  Board certification certificate, or  Residency/fellowship completion certificate if not board certified Further Description Of Experience Of The Medical Director • Number of years of nuclear cardiology/medicine/PET experience:       • Number of years as Medical Director of this laboratory:       Medical Director Responsibilities: • The Medical Director is responsible for all nuclear services provided including quality control, radiation safety and the quality and appropriateness of care provided. yes no • The Medical Director is responsible for assuring compliance of medical and technical staff to the standards outlined in the ICANL Standards. yes no • The Medical Director assures compliance with all policies/procedures/protocols and reviews all manuals periodically as necessary (minimum every three years) or as new policies are introduced. yes no • The Medical Director provides active oversight of radiation safety within the facility as evidenced by membership on the institution’s radiation safety committee or periodic review of radiation safety issues and documentation (if no radiation safety committee). The radiation protection program content and implementation are reviewed at least annually. yes no If “no” for any of the above four items please explain:      • The Medical Director delegates the above responsibilities to other personnel yes no, If yes, specify responsibilities and to whom they are delegated:      • Does the medical director personally supervise stress testing yes no, Version 3.0 ICANL Accreditation Application Extra Forms
  5. 5. If yes attach BLS/ACLS certification Continuing Medical Education (CME) Using the CME form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear medicine, list only the number of hours specifically related to nuclear medicine. If you have more CME to report than fits on this form, you do not have to list all CME once you have documented 15 hours of relevant CME credit within the past three years. (Documentation of earned CME credits must be on file and available for inspection. Do not submit any CME certificates or transcript lists.) ICANL CME Form (must be completed) Medical Director Course Dates Course name CME type: AMA Hours relevant Cat I, etc. to nuclear cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 • Total number of CME hours directly related to nuclear medicine earned in the past three years:       Certification By The Medical Director • I certify that the information regarding my experience and involvement with the laboratory is accurate and current. Name:       Signature: Date:      Version 3.0 ICANL Accreditation Application Extra Forms
  6. 6. Technical Director All questions must be answered. Do not submit a curriculum vitae.) Name:       Degree initials:       E-mail Address:       Education And Training Information • Nuclear Medicine Technologist Training: Name of Institution:       Location:       Dates: from       to       Certification: CNMT RT(N) State license NCT Training And Experience Of The Technical Director • Check all that apply An appropriate credential in nuclear medicine technology (RT (N), CNMT and/or state license) Three years or more of clinical experience in nuclear medicine/nuclear cardiology Current BLS (Basic life Support) certification  Enclose a copy of current nuclear medicine technologist registration card/license and BLS certification card. Further Description Of Experience Of The Technical Director • Number of years of nuclear medicine/nuclear cardiology experience:       • Number of years as Technical Director of this laboratory:       Duties Of The Technical Director • The Technical Director is responsible for the day-to-day operations of the laboratory. yes no, • The Technical Director assesses competency of technical staff on an annual basis yes no, If “no” for any of 1.2.2 above please explain:      Continuing Education (CE) Using the CE form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear medicine or nuclear cardiology, list only the number of hours specifically related to nuclear medicine or nuclear cardiology. If you have more CE to report than fits on this form, you do not have to list all CE once you have documented 15 hours of relevant CE credit within the past three years. (Documentation of earned CE credits must be on file and available for inspection. Do not submit any CE certificates or transcript lists.) Version 3.0 ICANL Accreditation Application Extra Forms
  7. 7. ICANL CE Form (must be completed) Technical Director Course Dates Course name CE type: Hours relevant to VOICE, etc. nuclear medicine/cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 • Total number of CE hours directly related to nuclear medicine/nuclear cardiology earned in the past three years:       Certification By The Technical Director • I certify that the information regarding my experience and involvement with the laboratory is accurate and current. Name:       Signature: Date:       Version 3.0 ICANL Accreditation Application Extra Forms
  8. 8. Interpreting Medical Staff (For each member of the medical staff interpreting studies in the laboratory, please provide the following information. All questions must be answered. Do not submit a curriculum vitae.) Name:       MD DO E-mail Address:       • Physician Licensure: • State(s):       Expiration Date(s):        Enclose a copy of current medical license(s) for geographical areas related to this application. Education And Training Information (do not include curriculum vitae) • Medical education: Medical School:       Year MD/DO degree:       • Residency training: Institution:       Location:       Specialty:       Dates: from      to       Number of months dedicated to nuclear cardiology:       • Fellowship training: Institution:       Location:       Specialty:       Dates: from       to       Number of months dedicated to nuclear cardiology:       Training And Experience Of The Interpreting Medical Staff Nuclear Cardiology: • Check at least one Certification in nuclear cardiology by the Certification Board of Nuclear Cardiology (CBNC). Board certified (or Board eligible but within two years of finishing training in Cardiology) and completion of a minimum of a 4 month formal (Level 2 1995 ACC/ASNC COCATS Training Guidelines) training program in nuclear cardiology. This requirement applies only to cardiologists who began their cardiology training in July 1995 or later. Board certified in cardiology and training equivalent to Level 2 training, or at least one year of nuclear cardiology practice experience with independent interpretation of at least 600 nuclear cardiology studies. This requirement applies only to cardiologists who began their cardiology training before July 1995. Board certified (or Board eligible but within two years of finishing training) in Nuclear Medicine Board certified (or Board eligible but within two years of finishing training) in Radiology with at least 4 months of nuclear cardiology training. Board certified (or Board eligible but within two years of finishing training) in radiology and at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 600 nuclear cardiology studies. Version 3.0 ICANL Accreditation Application Extra Forms
  9. 9. Board certified (or Board eligible but within two years of finishing training) in any other medical specialty recognized by the American Board of Medical Specialties or American Osteopathic Association and at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 600 nuclear cardiology studies. Ten years of nuclear cardiology practice experience with interpretation of at least 600 nuclear cardiology examinations. Nuclear medicine and/or PET: • Check at least one Board certified (or Board eligible but within two years of finishing training) in nuclear medicine. Board certified (or Board eligible but within two years of finishing training) in radiology with special competence in nuclear medicine. Board certified (or Board eligible but within two years of finishing training) in radiology with at least 4 months of nuclear medicine training with interpretation of at least 800 nuclear medicine procedures. Board certified (or Board eligible but within two years of finishing training) in any other medical specialty recognized by the American Board of Medical Specialties (ABMS) or American Osteopathic Association and at least one year (full time equivalent) of nuclear medicine practice experience with independent interpretation of at least 1000 general nuclear medicine procedures and/or, if performing nuclear medicine therapies, independent performance of a least 20 nuclear medicine therapies. Ten years of nuclear medicine practice experience with independent interpretation of at least 1000 general nuclear medicine procedures and/or, if performing therapies, independent performance of at least 20 nuclear medicine therapies.  Provide copies of appropriate documentation such as:  CBNC certificate or  Board certification certificate, or  Residency/fellowship completion certificate if not board certified Further Description Of Experience Of The Interpreting Medical Staff • Number of years of nuclear cardiology/medicine/PET experience:       • Number of years as interpreting medical staff member of this laboratory:       Responsibilities Of The Interpreting Medical Staff Member. • This interpreting medical staff member provides the final interpretation and report of the clinical nuclear cardiology studies. yes no If no, please explain:       • Does the medical director personally supervise stress testing yes no, If yes attach BLS/ACLS certification Continuing Medical Education (CME) Using the CME form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear cardiology/medicine/PET, list only the number of hours specifically related to nuclear cardiology/medicine/PET. If you have more CME to report than fits on this form, you do not have to list all CME once you have documented 15 hours of relevant CME credit within the past three years. (Documentation of earned CME credits must be on file and available for inspection. Do not submit any CME certificates or transcript lists.) Version 3.0 ICANL Accreditation Application Extra Forms
  10. 10. ICANL CME Form (must be completed) Medical Staff Course Dates Course name CME type: AMA Hours relevant Cat I, etc. to nuclear cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 • Total number of CME hours directly related to nuclear cardiology/medicine/PET earned in the past three years (15 hours of AMA Cat I CME mandatory January 1, 2004):       Certification By The Interpreting Medical Staff • I certify that the information regarding my experience and involvement with the laboratory is accurate and current. Name:       Signature: Date:      Version 3.0 ICANL Accreditation Application Extra Forms
  11. 11. Nuclear Medicine Technologist Staff (This section must be completed for each technical staff member, including all full or part time staff members. All questions must be answered. Do not submit a curriculum vitae.) Name:       Degree initials:       E-mail Address:       Education And Training Information (do not include curriculum vitae) • Nuclear Medicine Technologist Training: Name of Institution:       Location:       Dates: from       to       Certification: CNMT RT(N) State license NCT PET Training And Experience Of The Nuclear Medicine Technologist • Check all that apply An appropriate credential in nuclear medicine technology (RT (N), CNMT and/or state license) Current BLS (Basic life support) certification (include copy of current BLS certification)  Enclose a copy of current nuclear medicine technologist registration card/license and BLS certification card. (Label Part I, attachment 9) Further Description Of Experience Of The Nuclear Medicine Technologist • Number of years of nuclear medicine/nuclear cardiology experience:       • Number of years as nuclear medicine technologist in this laboratory:       Responsibilities Of The Nuclear Medicine Technologist Reports to the Technical Director yes no Responsible for image acquisition and performance of procedures yes no If “no” to either of the above please explain.       Continuing Medical Education (CE) Using the CE form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear medicine or nuclear cardiology, list only the number of hours specifically related to nuclear medicine or nuclear cardiology. If you have more CE to report than fits on this form, you do not have to list all CE once you have documented 15 hours of relevant CE credit within the past three years. (Documentation of earned CE credits must be on file and available for inspection. Do not submit any CE certificates or transcript lists.) Version 3.0 ICANL Accreditation Application Extra Forms
  12. 12. ICANL CE Form (must be completed) Technical Staff Course Dates Course name CE type: Hours relevant to VOICE, etc. nuclear medicine/cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 • Total number of CE hours directly related to nuclear medicine/nuclear cardiology earned in the past three years:       Certification By The Technical Staff • I certify that the information regarding my experience and involvement with the laboratory is accurate and current. Name:       Signature: Date:      Version 3.0 ICANL Accreditation Application Extra Forms
  13. 13. Equipment and Instrumentation For each imaging system, complete the table below. This form can be used to list three imaging systems. If more space is needed to list additional equipment use the separate “Additional Forms” file for additional instrumentation tables. Instrumentation Table Imaging Systems #1 #2 #3 Manufacturer                   Model                   Year of manufacture                   SPECT or planar                   Number of detectors                   PET - Gamma or dedicated                   Full or partial ring                   Acquisition computer                   Processing computer                   Display computer                   Stationary or mobile                   Preventative maintenance                   Version 3.0 ICANL Accreditation Application Extra Forms

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