1RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY
515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5029 • www.acgme.o...
GLOSSARY OF TERMS
A. Terms used in Program Requirements (PR)
Should: Is used for those dimensions of a training program wh...
Institution Type of Relationship:
Affiliated: The program may establish an affiliated relationship with another institutio...
Program Merge/Split/Absorption: In a merger, two programs combine to create one new program; the new program
becomes the a...
INDEX - RADIATION ONCOLOGY
Topic Section(s) Topic Section(s)
Actively Enrolled Residents 3.B Residents 6
Aggregate Data of...
RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY
515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5029 • www.acgme.or...
Part 2 Section Page(s)
Evaluation 11.G
topic1569.doc vii
11RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY
515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5029 • www.acgme....
5. Provide a detailed description of the grievance (due process) procedure that is available to residents, including the
c...
SECTION 5. FACULTY/STAFF
1. List in the following order full-time radiation oncologists, physicists, and radiation or canc...
SECTION 6. RESIDENTS
If requesting an increase in the number of approved resident positions in Part 1, Section 3.A., expla...
SECTION 7. SPACE AND EQUIPMENT
Institution #1
(Primary)
Institution #2 Institution #3 Institution #4 Institution #5
TOTAL ...
Institution #1
(Primary)
Institution #2 Institution #3 Institution #4 Institution #5
RADIOBIOLOGY (List major equipment)
D...
SECTION 8. MEDICAL DATA
Inclusive Dates for most recent 12-month period FROM: TO:
RADIATION ONCOLOGY
Institution #1
(Prima...
Number and Types of Neoplasms Seen in
Consultation
Institution #1
(Primary)
Institution #2 Institution #3 Institution #4 I...
SECTION 9. SUMMARY OF RESIDENT EXPERIENCE LOGS
A. Summary experience should be included for all current residents in the p...
B. Summary experience should be included for all residents who have completed the program during the last 3 years. (Use Su...
SECTION 10. EDUCATIONAL PROGRAM
A. Rotations
Outline of the training program in Radiation Oncology
PROVIDE AN OUTLINE OF T...
1. Intradepartmental
Is resident attendance
required?
Number of conferences
held annually
YES ( ) NO ( )
YES ( ) NO ( )
YE...
SECTION 11. NARRATIVE DESCRIPTION OF TRAINING PROGRAM
The narrative is an important part of the program information form. ...
e. Brachytherapy, intracavitary and interstitial, LDR and/or HDR.
f. Eye plaques.
g. Intraoperative radiation therapy.
h. ...
12. Describe resident participation in follow-up clinics.
13. Do residents or faculty ever see patients in consultation al...
c. How is effectiveness of the conferences evaluated?
d. What mechanism is used to ensure resident attendance at required ...
5. Describe the journal club in terms of how frequently it meets and resident participation. Provide dates that the journa...
Please attach a copy of the forms used by the residents to evaluate faculty and the program (Supplement H).
3. Internal Re...
ATTACH AS SUPPLEMENTS
SUPPLEMENT A Single site sponsor letter of commitment (if applicable)
SUPPLEMENT B Use the attached ...
SUPPLEMENT B. CURRICULUM VITAE
CV SHOULD BE CONDENSED TO FIT THIS PAGE. DO NOT ADD ADDITIONAL PAGES.
Name:
Present Positio...
SUPPLEMENT C. 2002-2003 RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG
INSTRUCTIONS
1. Complete the log and give a copy of it ...
SUPPLEMENT C. 2002-2003 RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG
The completed form should be given to the Program Direc...
Type # Cases
Thorax: Other
Benign: Heterotopic Bone
Benign: Eye
Benign: Other (does not fit in other categories)
All Other...
2. Pediatric External Beam Simulated:
Pediatric Cases: Primary Institution # Simulated Outside Institution(s) # Simulated
...
4. Specific Radiotherapy Techniques: Cases As Primary Resident in Treatment Planning
Type # Simulated
Mantle
Craniospinal
...
SUPPLEMENT D. AFFILIATION/INTEGRATION AGREEMENTS
Attach affiliation and/or integration agreements for all institutions lis...
SUPPLEMENT F. BIBLIOGRAPHY
List publications from the last five years by members of the active teaching staff and by the r...
SUPPLEMENT G. REPORTING FORMS FOR BRACHYTHERAPY / PEDIATRIC RADIATION
ONCOLOGY OUTSIDE ROTATIONS
ANY AFFILIATION OUTSIDE T...
SUPPLEMENT G. RADIATION ONCOLOGY: REPORT A
RRC FOR RADIATION ONCOLOGY AFFILIATED INSTITUTION REPORT: PEDIATRIC RADIATION O...
SUPPLEMENT G. PEDIATRICS: REPORT B
RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG
For pediatric experience in an outside affil...
SUPPLEMENT G. BRACHYTHERAPY: REPORT A
RRC FOR RADIATION ONCOLOGY AFFILIATED INSTITUTION REPORT: BRACHYTHERAPY
TO BE COMPLE...
SUPPLEMENT G. BRACHYTHERAPY: REPORT B
RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG - For brachyteraphy experience in an outs...
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  1. 1. 1RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5029 • www.acgme.org PROGRAM INFORMATION FORM 1FOR CONTINUED ACCREDITATION GENERAL INSTRUCTIONS 1This is the PIF for programs seeking continued accreditation. Go to the Web Accreditation Data System (Web ADS) found on the ACGME home page (www.acgme.org), using your previously assigned username and password, update your program and resident data, retrieve Part 1 of the PIF under the Site Visit Information section, complete the shaded items (as appropriate), print all sections of Part 1 of the PIF and sign the form. If you find items displayed incorrectly change your data using ADS update sections; in some instances you may need to contact your DIO for the entry of updated information. Next proceed to the section under the RRC for Radiation Oncology to retrieve Part 2 of the PIF for continued accreditation in either Word or WordPerfect. Complete Part 2 of the PIF using your preferred word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pages consecutively on the upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents (found with the Part 2 instructions). Send ONE copy of the entire packet to the site visitor to arrive 10 working days in advance of the survey date. After the site visit, send 3 complete copies of the PIF to the Executive Director of the RRC for Radiation Oncology at the above address. For accredited programs the entry on the TITLE OF PROGRAM line should correspond to the title of the program in the current ACGME’s Accredited Program Listing. If a change in title is being requested, this should be included in a cover letter accompanying the forms. The Program Director is responsible for the composition and accuracy of the information supplied in this form. Data for participating institutions must be collected by the Program Director and entered on a single set of forms. All sections of the form must be completed fully so that no questions are left unanswered and no items of information omitted. When the answer to a question is negative or "none," this should be indicated. Do not attach materials such as reprints, brochures, or annual reports, unless requested. Contact the RRC Administrator (Phone: 312-755-5042) with questions. Terms utilized are defined in glossary. The Institutional Requirements and the Program Requirements may be downloaded from the ACGME Website (www.acgme.org), should be reviewed carefully. The PIF must be signed by the Program Director and DIO of the sponsoring institution. The completed form may be secured with a rubber band or a large staple, or it may be loosely enclosed in protective materials. DO NOT punch holes in the form. DO NOT use any kind of process to bind the form or attach it to anything. Identify as the SPONSORING INSTITUTION that entity which has administrative responsibility for the program, as evidenced by the fact that it monitors the quality of the education, coordinates accreditation activity, administers the funding of the residency and pays the accreditation bills. If the SPONSORING INSTITUTION and the PRIMARY HOSPITAL are one and the same, the hospital’s name should be entered in the section requesting NAME AND ADDRESS OF SPONSORING INSTITUTION and in the section requesting PRIMARY HOSPITAL. Information requested regarding “length of assignment in months” for each hospital is used to determine which of the participating hospitals qualify as major participating or other participating institutions. The addition or deletion of major sites requires RRC approval and only GMED listing hospitals providing the equivalent of six months or more of the required 48 months of training will be included in the listing. The following supplements must be labeled and attached to each PIF: SUPPLEMENT A: Single Site Sponsoring Institution Letter of Commitment (if applicable) SUPPLEMENT B: Curricula Vitae SUPPLEMENT C: Resident Experience Logs SUPPLEMENT D: Affiliation / Integration Agreement SUPPLEMENT E: Research Programs SUPPLEMENT F: Bibliography SUPPLEMENT G: Reporting Forms/Logs for Brachytherapy/Pediatric Radiation Oncology SUPPLEMENT H: Evaluation Forms topic1569.doc i
  2. 2. GLOSSARY OF TERMS A. Terms used in Program Requirements (PR) Should: Is used for those dimensions of a training program which are so important that their absence must be justified. If the program has an alternative way to accomplish the intent of the requirement, this should be fully described. A program is at risk if it is not in compliance with a “should.” Must: Indicates that something is required and connotes an absolute requirement. Essential: Equates with indispensable and definitely identifies an absolute requirement. Desirable: “Desirable” or “highly desirable” are phrases used for aspects of a training program which are not absolutely essential but are considered to be very significant. B. Procedure Log Definitions Simulated Patient: A simulated patient is defined as a patient for whom the resident is involved in the initial simulation (whether done on a simulator or treatment machine and treatment planning of the patient. Performed Procedures: Procedures are considered performed by a resident if the resident performs approximately half of the brachy procedure and it is not counted as a performed procedure by another resident. Observed Procedure: Procedures are considered “observed” by a resident if the resident observes the entire procedure performed. Observed procedures do not require (hands on) work, but rather close observation. Pediatric Patient: Any patient who is less than 18 years of age is considered a pediatric patient. C. Terms used in the Program Information Forms (PIF) and Other terms used in Graduate Medical Education (GME) Applicant: Persons invited to come for an interview for a GME program. Categorical Position: (see also “Graduate Year 1" and “Preliminary Positions”) - Positions for residents who begin and remain in a given program or specialty until completion of the year(s) required for admission to specialty board examination. Consortium: Two or more organizations or institutions that have come together to pursue common objectives (e.g. GME). A consortium may serve as a “sponsoring institution” for GME programs if it is formally established as an ongoing institutional entity with a documented commitment to GME. Designated Institutional Official (DIO): The person in a sponsoring institution of GME who assumes the authority and responsibility for the GME programs and oversees the implementation of the Institutional Requirements. The DIO is responsible for completing the Annual Update for the Web Accreditation Data System and seeing that all sponsored programs complete their updates on schedule. Elective: Indicates a rotation/experience that may be chosen at the resident’s discretion in consultation with the faculty. Fellow: A term used by some sponsoring institutions and in some specialties to designate participants in subspecialty GME programs. Such physicians may also be termed "resident" as well. Other uses of the term "fellow" require modifiers for precision and clarity, e.g. "research fellow." Institution: An organization having the primary purpose of providing educational and/or health care services (e.g. a university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation). Major Participating Institution: An institution to which residents rotate for a required experience and/or those that require explicit approval by the appropriate RRC prior to utilization. Major participating institutions are listed as part of an accredited program in the Graduate Medical Education Directory. Participating Institution: An institution that provides specific learning experiences within a multi-institutional program of GME. Subsections of institutions, such as department, clinic, or unit of a hospital do not qualify as participating institutions. Sponsoring Institution: The institution that assumes the ultimate responsibility for a program of GME. topic1569.doc ii
  3. 3. Institution Type of Relationship: Affiliated: The program may establish an affiliated relationship with another institution for the purpose of limited rotations. Rotations to affiliated institutions may not exceed 6 months. Integrated: An institution may be considered integrated when the Program Director a) appoints the members of the faculty and is involved in the appointment of the chief of service at the integrated institution, b) determines all rotations and assignments of residents, and c) is responsible for the overall conduct of the educational program in the integrated institution. There must be a written agreement between the sponsoring institution and the integrated institution stating that these provisions are in effect. Rotations to integrated institutions are not limited in duration. Institutional Review: The process undertaken by the ACGME to judge whether a sponsoring institution offering GME programs is in substantial compliance with the Institutional Requirements. Intern: Historically, “intern” was used to designate individuals in the first year of GME; less commonly it designates individuals in the first year of any residency program. Since 1975, the Graduate Medical Education Directory and the ACGME have not used the term, instead referring to individuals in their first year of GME as residents. Internal Review: The formal process undertaken by a sponsoring institution of its individual ACGME accredited programs in conformity with Section I.B.3.c of the Institutional Requirements to evaluate the sponsored programs. International Medical Graduate (IMG): A graduate from a medical school outside the United States and Canada (and not accredited by the Liaison Committee on Medical Education (LCME)). IMG’s may be citizens of the United States who chose to be educated elsewhere or non-citizens who were admitted to the United States by US Immigration authorities. All IMG’s should undertake residency training in the United States before they can obtain a license to practice medicine in the United States even if they were fully trained, licensed, and practicing in another country. Medical School Affiliation: Institutions that sponsor an accredited program may have a formal relationship with a medical school. Indicate that a medical school affiliation exists for an institution (or program) if the institution (or program) is an important part of the teaching program for the medical school. Do not include only brief, occasional, and/or unique rotations of students or residents. Months of Rotation: Refers to the total number of months a typical resident spends at an institution. If the total number of months that each resident spends at a location is different for different residents, use the average (a decimal number may be reported). Ownership Type of Institution: Refers to the governance, control, or type of ownership of the institution. Program: The unit of specialty education, comprising a series of graduated learning experiences in GME, designed to conform to the program requirements of a particular specialty. Preliminary Positions (see also “Graduate Year 1"): Positions for residents who are obtaining training required to enter another program or specialty. Some residents in preliminary positions may move into permanent positions in the second year. Preliminary positions are usually 1 year in length and usually offered for Graduate Year 1. Internal medicine, surgery, and transitional year programs commonly offer preliminary positions. Preliminary Designated Positions: Residents matched by/for other specialties. The resident is designated as having a permanent position after completing the preliminary year(s). Specialties that do not designate preliminary positions will use this option to indicate preliminary positions. Preliminary Non-Designated: Residents accepted into the program for 1 or 2 years of training; these residents do not have designated permanent positions in the current program or another program at time of acceptance. Primary Teaching Hospital: If the sponsoring institution is a hospital, it is by definition the principal or primary teaching hospital for the residency program. If the sponsoring institution is a medical school, university, or consortium of hospitals, the hospital that is used most heavily in the residency program is the principal teaching hospital. Program Director: The official responsible for maintaining the quality of a GME program so that it meets ACGME accreditation standards. Other duties of the Program Director preparing a written statement outlining the program’s educational goals; providing an accurate statistical and narrative description of the program as requested by the Residency Review Committee (RRC); and providing for the selection, supervision, and evaluation of residents for appointment to and completion of the program. topic1569.doc iii
  4. 4. Program Merge/Split/Absorption: In a merger, two programs combine to create one new program; the new program becomes the accredited unit and accreditation is voluntarily withdrawn from both former programs. In a split, one program divides into two separate programs and each program receives accreditation. In absorption, one program takes over the other program; the absorbed program is granted voluntary withdrawal status, while the other program remains accredited. Program Letters of Agreement: The sponsoring institution must ensure that for each accredited program appropriate letters of agreement exist between the sponsoring institution and the participating institutions used by a program that provides specific learning experiences. Program Year (see also “Graduate Year”): Refers to the current year of training within a specific program; this may or may not correspond to the graduate year. For example, a resident in pediatric cardiology could be in the first program year of the pediatric cardiology program but in his/her fourth graduate year of GME (including 3 prior years of pediatrics). The Web Accreditation Data System tracks residents according to his/her current year in the program, regardless of prior training. Required: Designates those rotations/experiences required by the program of all residents although they may choose which month or year they are to be taken. Resident: A physician at any level of GME in a program accredited by the ACGME. Participants in accredited subspecialty programs are included. Other uses of the term “resident” require modifiers. Scholarly Activity: Educational experiences that include active participation of the teaching staff in clinical discussions, rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship; active participation in journal clubs, research conferences, regional or national professional and scientific societies, particularly through presentations at the organizations’ meetings and publications in their journals; participation in research, particularly in projects that are funded following peer review and/or result in publications or presentations at regional and national scientific meetings; offering of guidance and technical support (e.g., research design, statistical analysis) for residents involved in research; and provision of support for resident participation as appropriate in scholarly activities. May be defined in more detail in specific Program Requirements. Sponsoring Institution (See also “Institution”): The institution that assumes the ultimate responsibility for a program of GME. Substantial Compliance: The determination of substantial compliance results from a judgment based on all available information as to the degree that the entity being evaluated meets accreditation standards. Suggested: A term, along with its companion “strongly suggested,” used to indicate that something is distinctly urged rather than required. An institution or a program will not be cited for failing to do something that is suggested or strongly suggested. Teaching Staff: Any individual who has received a formal assignment to teach resident physicians. In some institutions appointment to the medical staff of the hospital constitutes appointment to the teaching staff. topic1569.doc iv
  5. 5. INDEX - RADIATION ONCOLOGY Topic Section(s) Topic Section(s) Actively Enrolled Residents 3.B Residents 6 Aggregate Data of Residents Completing or Leaving the Program 3.C Residents who Completed the Program 3.D Background Information 4 Rotations 10.A Basic Information 1 Space and Equipment 7 Clinical Program 11.A Sponsoring Institution/Single Residency Institution 4.C Conferences 10.B Didactic Program 11.E Educational Program 10 Evaluation 11.G Faculty/Staff 5 General Competencies 4.B Library Resources 10.C Medical Equipment 8 Narrative Description of Training Program 11 Number of Positions 3.A Other Residencies 4.E Outside Rotations 11.D Participating Institutions 2 Program Outcomes–Scholarly Activity 3.E Research 11.G Resident Complement 3 Resident Duty Hours 11.C Resident Experience Logs 9, Supplement D Resident Log Evaluation 11.B topic1569.doc v
  6. 6. RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5029 • www.acgme.org PROGRAM INFORMATION FORM 10 Digit ACGME Program I.D. #: (for continued accreditation) Program Name: TABLE OF CONTENTS When you have the completed forms, number each page sequentially in the upper right hand corner. Start on Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page with the completed PIF. 1Part 1 Section Page(s) General Program Information 1 Accreditation Information 1.A Program Director Information 1.B Participating Institutions 2 Resident Complement 3 Number of Positions 3.A Actively Enrolled Residents 3.B Aggregate Data on Residents Completing or Leaving the Program for the Last Three (3) Years 3.C Residents Who Completed the Program 3.D Withdrawn / Dismissed Residents 3.E Scholarly Activity 3.F Duty Hours 3.G Part 2 Section Page(s) Background Information 4 Previous Citations or Concerns 4.A Changes 4.B Sponsoring Institution/Single Residency Institution 4.C General Competencies 4.D Other Residencies 4.E Faculty/Staff 5 Residents 6 Space and Equipment 7 Medical Equipment 8 Resident Experience Logs 9 Educational Program 10 Rotations 10.A Conferences 10.B Library Resources 10.C Narrative Description of Training Program 11 Clinical Program 11.A Resident Log 11.B Resident Duty Hours 11.C Outside Rotations 11.D Didactic Program 11.E Research 11.F topic1569.doc vi
  7. 7. Part 2 Section Page(s) Evaluation 11.G topic1569.doc vii
  8. 8. 11RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5029 • www.acgme.org PROGRAM INFORMATION FORM (PART 2) 1FOR CONTINUED ACCREDITATION SECTION 4. BACKGROUND INFORMATION A. Previous Citations or Concerns List each of the citations or concerns, if any, from the notification letter that was sent following the last survey and review of the program, and which contained an accreditation action, and briefly and concisely describe the steps that have been taken to correct the problem. If you submitted a subsequent progress report to the RRC, please reiterate your comments for verification by the site visitor. If such correction is documented in the program information form you prepare for this review, provide page references. B. Changes Briefly describe major changes, other than those included in the response to the previous citations and/or concerns (above), that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, resident complement, etc. C. Sponsoring Institution/Single Residency Institution (see ACGME Institutional Requirements) For those institutions which are either a single-program institution (e.g., radiation oncology only), or an institution with multiple residencies accredited by the same Residency Review Committee, the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions. Complete only if "single/limited site sponsor" field in Part 1, Section 2 is yes. 1. Provide a letter indicating the commitment of the sponsoring institution, its governing body, the administration, and the teaching staff to the residency/residencies and its pledge to provide the required financial and educational resources (Supplement A). 2. Provide a description of the method by which the sponsoring institution will monitor the residency/residencies to ensure that it has the educational and financial resources to meet the Program Requirements. If regular internal reviews of the program’s educational quality and compliance with ACGME requirements occur, please describe the progress and explain how residents and faculty are involved in the program’s evaluation. 3. Provide a summary statement of how the institution complies with Section II.A, regarding “Resident Eligibility and Selection” requirements and development of appropriate policies in accordance with the ACGME Institutional Requirements. 4. Provide a summary statement of how the institution complies with Section II.C, of the ACGME Institutional Requirements regarding resident support, benefits and conditions of employment to include the details of the resident contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the resident contract/agreement to the PIF, but state when it is given to the residents and applicants and have a copy available for verification by the site visitor on the day of the survey with the various items numbered according to the Institutional Requirements under II.C.) topic1569.doc viii
  9. 9. 5. Provide a detailed description of the grievance (due process) procedure that is available to residents, including the composition of the committee and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a resident’s contract, or other actions that could significantly threaten a resident’s intended career development. D. General Competencies In 2002, the ACGME began to monitor the implementation of general competencies and assessment for all existing core programs by using a common data collection tool. Log onto the Web Accreditation Data System and proceed to the Site Visit Information section and select Update/Verify General Competency Addendum to enter your information. Once the information has been entered and saved, select Print PIF Competencies Addendum to generate a printed copy of the General Competencies Addendum and attach it to the end of PIF. E. Other Residencies What other accredited residency programs are conducted by the primary teaching institution? topic1569.doc ix
  10. 10. SECTION 5. FACULTY/STAFF 1. List in the following order full-time radiation oncologists, physicists, and radiation or cancer biologists under whom the work of the resident staff is performed. Include only faculty that are directly involved in teaching residents. Do not include staff from other medical specialties, such as medical oncology, nuclear medicine, diagnostic radiology, etc. (Provide CV for each staff listed using Supplement B.) Name Degree Academic Rank (1) Hospital (2) Present Clinical Specialization (3) Date Certified by ABR (4) 1. Is the staff an instructor, associate professor, assistant professor, etc.? 2. Indicate the Institution Number for each staff member. 3. Radiation Oncologist, Radiation Physicist, Radiation or Cancer Biologist, or other Specialty. 4. ABR: Indicate whether certification is in Radiation Oncology, Therapeutic Radiology, General Radiology, Radiological Physics, or other specialty. If other Board, please specify. 2. How much time does the Program Director contribute to the direction of the program? Does the Program Director directly instruct and supervise residents? 3. Are there staff vacancies? If so, what is being done to fill them? 4. List in the following order part-time radiation oncologists, physicists, and radiation or cancer biologists under whom the work of the resident staff is performed. Do not include staff from other medical specialties, such as medical oncology, nuclear medicine, diagnostic radiology, etc. (Provide CV for each staff listed using Supplement B.) Name Degree Academic Rank (1) Hospital (2) Present Clinical Specialization (3) Date Certified by ABR (4) 1. Is the staff an instructor, associate professor, assistant professor, etc.? 2. Indicate the Institution Number for each staff member. 3. Radiation Oncologist, Radiation Physicist, Radiation or Cancer Biologist, or other Specialty. 4. ABR: Indicate whether certification is in Radiation Oncology, Therapeutic Radiology, General Radiology, Radiological Physics, or other specialty. If other Board, please specify. topic1569.doc x
  11. 11. SECTION 6. RESIDENTS If requesting an increase in the number of approved resident positions in Part 1, Section 3.A., explain the educational rationale for the request. Describe any additional training positions (e.g., clinical or research fellows who have completed training in an accredited radiation oncology residency program): Do all residents have one year of postgraduate clinical training before beginning training in radiation oncology? YES ( ) NO ( ) What is the ratio of residents to staff? Do you provide affiliated or any other training for trainees from other institutions*? YES ( ) NO ( ) If YES, provide names of other institutions, describe the rotations and specify the number of resident-months in a given year allocated to residents rotating from other institutions. If the affiliated institution is utilized for pediatric or brachytherapy experience, please attach the designated resident experience forms as Supplement E and/or F. *i.e., the first year of training in radiation oncology. topic1569.doc xi
  12. 12. SECTION 7. SPACE AND EQUIPMENT Institution #1 (Primary) Institution #2 Institution #3 Institution #4 Institution #5 TOTAL GROSS SQUARE FOOTAGE DEVOTED TO: Radiation Oncology Physics Radiation Research Other (specify) ALLOCATION OF SPACE IN RADIATION ONCOLOGY (Specify number of each) Examining Rooms Resident Work Space (Offices) Staff Offices Clinical Physics Biology Conference Rooms Treatment Planning Rooms Treatment Aid Construction Room Laboratories: Radiobiology / Cancer Biology Physics Library Other EXTERNAL BEAM RADIOTHERAPY EQUIPMENT (Specify number of each) Kilovoltage Units (Superficial / Contact Therapy) Megavoltage Units Units with Electron Capability Intraoperative RT Units Hyperthermia Units Gamma Knife Units Linac Radiosurgery Units Other (Specify) PLANNING EQUIPMENT (Specify number of each) Fluoroscopic Simulators CT Simulators Treatment Planning Computer / Workstation 2-Dimensional Planning Computers 3-Dimensional Planning Computers IMRT Capability BRACHYTHERAPY EQUIPMENT (Specify with an X, if available) Low Dose Rate Remote After-Loading Machine(s) High Dose Rate Remote After-Loading Machine(s) Manual After Loading Applicator(s) Radioactive Sources - Specify Type RADIATION PHYSICS (List major equipment) topic1569.doc xii
  13. 13. Institution #1 (Primary) Institution #2 Institution #3 Institution #4 Institution #5 RADIOBIOLOGY (List major equipment) DESCRIBE OTHER EQUIPMENT (as needed), PARTICULARLY AS IT RELATES TO INNOVATIVE OR RESEARCH PROGRAMS, SUCH AS HEAVY PARTICLE RADIOTHERAPY, OR RADIO-LABELED ANTIBODIES topic1569.doc xiii
  14. 14. SECTION 8. MEDICAL DATA Inclusive Dates for most recent 12-month period FROM: TO: RADIATION ONCOLOGY Institution #1 (Primary) Institution #2 Institution #3 Institution #4 Institution #5 Total patients seen in consultation Total cases irradiated with external RT New Retreated: Number of Brachytherapy Procedures (PR) / Patients (P) PR P PR P PR P PR P PR P Intracavitary Interstitial Intravascular Unsealed radionuclide procedures Follow-up visits % of follow-up visits seen by residents What is the ratio of treated patients to FTE staff? NUMBER AND TYPES OF NEOPLASMS SIMULATED Institution #1 (Primary) Institution #2 Institution #3 Institution #4 Institution #5 Primary Brain, Pituitary, Spinal Cord Head and Neck Lung and Trachea Breast Gastrointestinal Genitourinary Gynecology Lymphomas, Leukemia, Myeloma Bone and Soft Tissue Skin Pediatric (under 18 years) Unknown primary Benign Other Secondary (Metastases) Does Department have a tumor registry? Does Hospital have a tumor registry? Does Department maintain an active follow- up system? topic1569.doc xiv
  15. 15. Number and Types of Neoplasms Seen in Consultation Institution #1 (Primary) Institution #2 Institution #3 Institution #4 Institution #5 Primary Brain, Pituitary, Spinal Cord Head and Neck Lung and Trachea Breast Gastrointestinal Genitourinary Gynecology Lymphomas, leukemia, myeloma Bone and soft tissue Skin Pediatric (under 18 years) Unknown primary Benign Other Secondary (Metastases) topic1569.doc xv
  16. 16. SECTION 9. SUMMARY OF RESIDENT EXPERIENCE LOGS A. Summary experience should be included for all current residents in the program. Note: Exclude time for research and rotations outside of Radiation Oncology. Name Dates included in resident log CNS Benign Breast Endocrine *** Bone / STS H&N GI GU GYN Lymphoma / Leukemia Skin Thorax Mets Unknown* *** Total Simulated Average # simulated/ RO yearAdult Peds Name Dates included in resident log Total Brachytherapy Procedures* Intracavitary** Interstitial** Performed Observed Performed Observed # of Patients # of Procedures # of Patients # of Procedures # of Patients # of Procedures # of Patients # of Procedures *Total insertions/applications performed (Adult and Peds). **Count only cases for which you were the primary resident responsible for performing the procedure. Do not count cases that are counted by another resident. ***New category. ****Previously "All Others." topic1569.doc
  17. 17. B. Summary experience should be included for all residents who have completed the program during the last 3 years. (Use Supplement C in combination with the online case log to collect the data.) Note: Exclude time for research and rotations outside of Radiation Oncology. Name Dates included in resident log CNS Benign Breast Endocrine *** Bone / STS H&N GI GU GYN Lymphoma / Leukemia Skin Thorax Mets Unknown **** Total Simulated Average # simulated/ RO yearAdult Peds Name Dates included in resident log Total Brachytherapy Procedures* Intracavitary** Interstitial** Performed Observed Performed Observed # of Patients # of Procedures # of Patients # of Procedures # of Patients # of Procedures # of Patients # of Procedures *Total insertions/applications performed (Adult and Peds). **Count only cases for which you were the primary resident responsible for performing the procedure. Do not count cases that are counted by another resident. ***New category. ****Previously "All Others." topic1569.doc
  18. 18. SECTION 10. EDUCATIONAL PROGRAM A. Rotations Outline of the training program in Radiation Oncology PROVIDE AN OUTLINE OF TYPICAL ASSIGNMENTS AND THE TIME SPENT IN EACH ASSIGNMENT. First Year Months Weeks Second Year Months Weeks Third Year Months Weeks Fourth Year Months Weeks SUMMARIZE BELOW THE TOTAL TIME DEVOTED IN YOUR RESIDENCY PROGRAM TO: Months Weeks Radiation Oncology Medical Oncology: Adult Medical Oncology: Pediatric Pathology Physics Didactic Course Radiation and Cancer Didactic Course Medical Statistics Didactic Course Diagnostic Imaging Others (including Electives) Detail: B. Conferences List regularly scheduled conferences including new patient conferences, problem case conferences, chart rounds, morbidity and mortality, radiobiology seminar, physics seminar, journal club, statistics, etc. topic1569.doc
  19. 19. 1. Intradepartmental Is resident attendance required? Number of conferences held annually YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) 2. Interdepartmental: Indicate individual(s) and specialty responsible for organization of the session. Is resident attendance required? Number of conferences held annually YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) C. Library Resources 1. Do residents have internet access 24 hours/day, 7 days a week? YES ( ) NO ( ) 2. Describe accessibility to residents of computerized literature search data bases: 3. Do residents have access to departmental and/or institutional libraries. YES ( ) NO ( ) topic1569.doc
  20. 20. SECTION 11. NARRATIVE DESCRIPTION OF TRAINING PROGRAM The narrative is an important part of the program information form. Please respond fully to the following questions. A. Clinical Program 1. Describe the program’s overall goals and objectives for each level of training and each major rotation. 2. Do the residents receive at least 36 months in clinical radiation oncology? 3. Describe the residents’ experience (both pediatric and adult) on medical oncology (or its equivalent). Explain how the time spent equals a minimum of two months. 4. Describe the residents’ experience in oncologic pathology, or an equivalent experience in the form of conferences and tumor boards. Explain how the time spent equals one month. 5. Describe the residents’ experience in diagnostic imaging, or an equivalent experience in the form of conferences and tumor boards. 6. Describe the residents educational experience in pain management and palliative care. 7. Do residents have elective rotations? If so, what electives are offered and what is the duration of the elective rotations? Approximately what proportion of residents take each elective rotation? 8. What opportunities do radiation oncology residents have to exchange knowledge and experience with a) each other, b) residents from other oncology specialties, and c) residents from other ACGME accredited programs, including medicine and surgery? Describe how this occurs. 9. Describe how residents are trained in the following (including, where appropriate, the applicability of the modality or technique): a. Diagnosis, patient evaluation, staging, recommending, and implementing treatment. b. Megavoltage radiotherapy including electron beam. c. Computerized treatment planning, 2-dimensional, 3-dimensional conformal and/or IMRT. d. Construction of treatment aids. topic1569.doc
  21. 21. e. Brachytherapy, intracavitary and interstitial, LDR and/or HDR. f. Eye plaques. g. Intraoperative radiation therapy. h. Hyperthermia. i. Intravascular brachytherapy. j. Radiosurgery. k. Radioimmunotherapy. l. Specialized beams (e.g., neutrons, alpha particles, etc.). m. Total skin irradiation. n. Total body irradiation. o. Unsealed radionuclides. 10. How is the optimal distribution of radiation dose taught? 11. How are residents taught about calibration and monitoring of equipment and radiation safety procedures, such as handling of radionuclides? topic1569.doc
  22. 22. 12. Describe resident participation in follow-up clinics. 13. Do residents or faculty ever see patients in consultation alone? If so, what percent are seen alone by residents? By faculty? 14. Describe resident participation in the department’s quality assurance program, such as chart rounds and port film checks. 15. Describe the availability of diagnostic radiology services, including CT and MRI, as well as nuclear medicine services, the pathology laboratory, the clinical laboratory, and tumor registry. B. Resident Log [Please note Supplement C] It is a requirement of the RRC that residents keep a log of all procedures they perform. Are the resident logs reviewed semi annually by the Program Director? C. Resident Duty Hours Are resident on-call hours within the ACGME requirements? D. Outside Rotations 1. Describe the rotations at all outside participating hospitals or facilities in terms of experience obtained, degree of resident responsibility for patient care, and provision of supervision. Explain further how each participating institution contributes uniquely to the educational program. 2. If residents are sent for additional experience to another institution where residents from other programs are also rotating, then provide the information as requested (Supplement D). E. Didactic Program 1. Describe conferences: a. How many conferences in radiation oncology do residents attend each week? b. Describe how residents participate in these conferences. For which conferences do residents have substantial responsibility? Describe faculty participation in conferences. topic1569.doc
  23. 23. c. How is effectiveness of the conferences evaluated? d. What mechanism is used to ensure resident attendance at required conferences? To what degree is faculty attendance expected? Is this monitored? e. How do resident rotations at affiliated or integrated institutions affect their ability to attend ongoing conferences? 2. Describe the radiation physics course: a. Does the course include both didactic lectures and lab demonstrations? b. How does the physicist interact with the residents? c. What is the mechanism for formal evaluation and feedback? e. List the texts used for course, and indicate the total number of formal teaching hours. f. Submit a course outline, including dates, presenters and topics. 3. Describe the radiobiology / cancer biology course (e.g., lecture, lab demonstration): a. How and by whom is the course taught? b. What is the mechanism for formal evaluation and feedback? c. List the texts used for the course, and indicate the total number of formal teaching hours. d. Submit a course outline, including dates, presenters and topics. 4. Describe the program of conferences or lectures to familiarize residents with medical statistics. Submit an outline of the sessions including dates, and names of lecturers or coordinators. topic1569.doc
  24. 24. 5. Describe the journal club in terms of how frequently it meets and resident participation. Provide dates that the journal club has met in the last year and names of responsible staff. F. Research 1. Describe briefly the research space and important special research facilities. 2. What opportunities currently exist in the department for resident initiated research? Is a resident research project required by the program? Provide a listing of research projects as Supplement E. 3. Does the department provide funding to residents to attend national meetings? How is it allocated? G. Evaluation 1. Residents a. Do faculty evaluate residents’ at the end of each clinical rotation? b. Does the Program Director meet with and evaluate residents at least semi annually? c. Are these meetings documented? d. Is the resident provided feedback from the faculty and the Program Director? e. Does the Program Director prepare a written final evaluation of the resident at the end of the training that’s kept on file by the institution? f. Do the evaluations include clinical skills, interpersonal skills, ability to communicate, professionalism, integrity and ethical behavior? Please attach a copy of the form used by the faculty to evaluate residents (Supplement H). 2. Faculty / Program a. Do the residents complete a confidential written evaluation of each faculty member and the program at year end? b. Does the evaluation include knowledge base, teaching skill, mentoring ability, delegation or responsibility and stimulus to do investigation? topic1569.doc
  25. 25. Please attach a copy of the forms used by the residents to evaluate faculty and the program (Supplement H). 3. Internal Review: Describe the mechanism for periodic internal (institutional) review and evaluation of the residency program. topic1569.doc
  26. 26. ATTACH AS SUPPLEMENTS SUPPLEMENT A Single site sponsor letter of commitment (if applicable) SUPPLEMENT B Use the attached form to provide a brief curriculum vitae for each member of the staff involved in this training program. A CV form should be provided for everyone listed as full-time and part-time staff. SUPPLEMENT C Attach Resident Experience Logs for all residents who have completed the program in the last three years and for all current residents. The inclusive dates of the resident experience must be provided on the logs. The log forms used must be the forms distributed by the Residency Review Committee for Radiation Oncology. SUPPLEMENT D Attach affiliation and/or integration agreements for all institutions listed in Section 2. The agreements should be signed and current (within the last 3 years.) SUPPLEMENT E List research programs (not more than ten) being conducted by faculty members, particularly those in which residents participate. Label as “Supplement E: Research Programs.” List faculty participation in professional societies. Label as “Supplement E: Faculty Participation in Professional Societies.” List resident presentations at local, regional, or national scientific meetings which have resulted from resident involvement in research. Label as “Supplement E: Resident Presentations.” SUPPLEMENT F Bibliography. List publications from the last 5 years by members of active teaching staff and by all the residents. SUPPLEMENT G Attach reporting forms/logs for pediatric radiation oncology and brachytherapy experience for all current residents. One of the two forms is a log used by the residents to record their participation in pediatric and brachytherapy cases on all outside rotations. The other form (Affiliated Institution Report) is to be filled out by the affiliate. SUPPLEMENT H Evaluation forms. topic1569.doc
  27. 27. SUPPLEMENT B. CURRICULUM VITAE CV SHOULD BE CONDENSED TO FIT THIS PAGE. DO NOT ADD ADDITIONAL PAGES. Name: Present Position: Academic Rank and institution where it is held: Address: City/State/ZIP: Education (including dates and degrees obtained): Hospital Training (including dates of internships, residencies, fellowships, etc.): Professional appointments: Certification: Licensure(s): Professional activities/committees: Brief statement regarding role in residency training program: topic1569.doc
  28. 28. SUPPLEMENT C. 2002-2003 RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG INSTRUCTIONS 1. Complete the log and give a copy of it to the Program Director at the end of the current training year. You must keep a copy for your reference and for cumulative recording. At the end of your training, you will be required to submit a cumulative log of your experience. (Incomplete forms will delay in processing records.) 2. Provide a response for each category. Count only SIMULATED cases for which you were the primary resident responsible for that patient. Do not count cases that are counted by another resident. Count cases only once. For example, for a uterine sarcoma the case should be counted only under a “GYN”, and not under both “sarcoma” and “GYN”. 3. Enter “0" if you did not perform any procedures for a given category. 4. If you performed procedures but the data are not available, provide a brief explanation. For example, you did not collect data for that category, you combined the data for two or more categories that are listed separately on the survey, or you are not sure if the procedures you performed fit a particular category. 5. If the procedures that you performed are similar to but not exactly the same as the procedures listed on the log, provide the number of similar procedures and write in the name(s) of the procedures. 6. For Pediatric patients simulated, indicate experience obtained both at the primary institution and on rotations outside the parent hospital. You may count only irradiated pediatric patients on whom you have done the initial simulation for treatment. For example, do not count a patient you interacted with during weekly on-treatment checks or follow-ups unless you were the primary resident in the simulation process for subsequent irradiation of the patient. 7. For Brachytherapy procedures, indicate procedures performed and procedures observed at the primary institution and on outside rotations. Count only cases on which you were the primary resident performing the procedure. Do not count it as a “procedure performed” if another resident also counts it as a procedure performed. 8. For Specific Radiotherapy Techniques, count only cases for which you have done the simulation and which are not also counted by another resident. RETURN THE COMPLETED LOG TO THE PROGRAM DIRECTOR BY JULY 1, 2003. topic1569.doc
  29. 29. SUPPLEMENT C. 2002-2003 RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG The completed form should be given to the Program Director by July 1, 2003. To be completed by the Program Director: TO BE COMPLETED BY THE PROGRAM DIRECTOR AT PRIMARY INSTITUTION. Program Number / Program Name City/State Program Director Name Signature TO BE COMPLETED BY THE RESIDENT (RESIDENTS ARE ALSO ENCOURAGED TO MAINTAIN A LIST OF SPECIFIC CASES). Resident Name Signature Time Period to be Covered by Log From: To: List institutions used for outside rotations: Dates: From - To 1. 2. 3. 1. Adult External Beam Simulated: Primary Site (Non-Metastatic Disease): Type # Cases Breast: Intact Breast: Post-Mastectomy Bone/Soft Tissue Sarcoma Central Nervous System Head/Neck: Intact Head/Neck: Post-Operative Gastrointestinal: Esophagus Gastrointestinal: Stomach Gastrointestinal: Pancreas Gastrointestinal: Hepatobiliary Gastrointestinal: Colon Gastrointestinal: Rectum Gastrointestinal: Anus Gastrointestinal: Other Genitourinary: Prostate Genitourinary: Bladder Genitourinary: Testes Genitourinary: Other Gynecologic: Cervix Intact Gynecologic: Cervix Post-Hysterectomy Gynecologic: Uterus Gynecologic: Other Hodgkin's Lymphoma Non-Hodgkin's Lymphoma Leukemia / Myeloma Other Hematologic Malignancies Skin Thorax: Small Cell Lung Cancer Thorax: Non-small Cell Lung Cancer topic1569.doc
  30. 30. Type # Cases Thorax: Other Benign: Heterotopic Bone Benign: Eye Benign: Other (does not fit in other categories) All Others (Give Examples) Total Primary Site Adult External Beam Total Secondary (Metastatic) Adult External Beam Simulated (Not Covered Above Under Primary Site) Total Adult External Beam Simulated Cases (Primary Plus Secondary [c equals total cases a plus b]) topic1569.doc
  31. 31. 2. Pediatric External Beam Simulated: Pediatric Cases: Primary Institution # Simulated Outside Institution(s) # Simulated Leukemia Medulloblastoma CNS (Non-Medulloblastoma) Hodgkins’s Lymphoma Non-Hodgkins’s Lymphoma Rhabdomyosarcoma / STS Ewing’s Sarcoma / Bone Tumor Neuroblastoma Retinoblastoma Wilms’ Tumor Other: Describe case(s) for Primary or other institution 3. Brachytherapy Primary Institution Outside Institution # Cases Performed # Cases Observed # LDR/HDR # Cases Performed # Cases Observed # LDR/ HDR INTRACAVITARY Number of Patients Number of Insertions Cervix / Uterus Endobronchial Esophagus / Bile Duct Other INTERSTITIAL (including seeds) Number of Patients Number of Implants Breast Soft Tissue Sarcoma Head & Neck Prostate GYN / Pelvis Other Surface Applications (moulds, plaque, Sr-90) Unsealed Sources (e.g. I-131 oral, P-32 colloid, Sr- 89, Sm-153, other) Endovascular Insertions topic1569.doc
  32. 32. 4. Specific Radiotherapy Techniques: Cases As Primary Resident in Treatment Planning Type # Simulated Mantle Craniospinal Total Body Irradiation Total Skin Irradiation Stereotactic Radiosurgery: Brain Stereotactic Radiosurgery: Other topic1569.doc
  33. 33. SUPPLEMENT D. AFFILIATION/INTEGRATION AGREEMENTS Attach affiliation and/or integration agreements for all institutions listed in Part 1, Section 2. The agreements should be signed and current (within the last 5 years.) A letter of agreement must be attached for all outside rotations for 3 months or less. For outside rotations of 3 months or less, letters of agreement between the Program Director and the individual responsible for the rotation must be available for review. Affiliation: The program may establish an affiliated relationship with another institution for the purpose of limited rotations. Rotations to affiliated institutions may not exceed 6 months. Integration: An institution may be considered integrated when the Program Director a) appoints the members of the faculty and is involved in the appointment of the chief of service at the integrated institution, b) determines all rotations and assignments of residents, and c) is responsible for the overall conduct of the educational program in the integrated institution. There must be a written agreement between the sponsoring institution and the integrated institution stating that these provisions are in effect. Rotations to integrated institutions are not limited in duration. topic1569.doc
  34. 34. SUPPLEMENT F. BIBLIOGRAPHY List publications from the last five years by members of the active teaching staff and by the residents. All articles by clinical faculty, physics faculty, biology faculty, and residents are to be included. All authors are to be included on each publication, including those who are not members of the radiation oncology staff (for example, if a medical oncologist was a co-author, her/his name should be included). The order of the authors should be as it appeared when the article was published. The names of radiation oncology staff (including clinical physics and radiobiology staff) should be underlined and the names of the residents should be followed by an asterisk(*). Indicate whether the publication was a peer reviewed full length publication, a review article/book chapter, or an abstract. List each publication only once. List in press or published articles only. Do not list ”submitted” articles, manuscripts “in progress”, etc. The bibliography is to be organized as shown in the outline below: I. Publications with principal emphasis on clinical oncology A. Peer reviewed articles B. Non-peer reviewed articles (e.g., subject reviews, book chapters) C. Abstracts II. Publications with principal emphasis on physics A. Peer reviewed articles B. Non-peer reviewed articles (e.g., subject reviews, book chapters) C. Abstracts III. Publications with principal emphasis on radiobiology A. Peer reviewed articles B. Non-peer reviewed articles (e.g., subject reviews, book chapters) C. Abstracts DO NOT INCLUDE REPRINTS. topic1569.doc
  35. 35. SUPPLEMENT G. REPORTING FORMS FOR BRACHYTHERAPY / PEDIATRIC RADIATION ONCOLOGY OUTSIDE ROTATIONS ANY AFFILIATION OUTSIDE THE PARENT OR INTEGRATED INSTITUTION Attach completed reporting forms / logs for pediatric radiation oncology and brachytherapy experience. One form is a log used by the residents to record their participation in pediatric and brachytherapy cases on all outside rotations. The completed resident log form should be collected by Program Directors semi-annually and reviewed with each resident. The second form (Affiliated Institution Report) is to be filled out annually by the affiliate. The Program Director is asked to provide these completed forms to the RRC when the program is surveyed. Both the institutional report and the experience logs should also be maintained by the Program Director as part of the permanent program record. Blank copies of these forms are appended to the PIF. topic1569.doc
  36. 36. SUPPLEMENT G. RADIATION ONCOLOGY: REPORT A RRC FOR RADIATION ONCOLOGY AFFILIATED INSTITUTION REPORT: PEDIATRIC RADIATION ONCOLOGY TO BE COMPLETED BY THE AFFILIATED INSTITUTION. Affiliated Institution Date Number of Radiation Oncology residents assigned to the affiliated institution at any given time Does institution have an ACGME accredited radiation oncology residency program? List all residents assigned for pediatric rotations during the past calendar year: Dates -From To Include visiting trainees as well as residents in your program. Use additional sheets if necessary. Attach pediatric logs filled out by visiting residents. Resident Name Name of Resident’s Home Program Dates of Rotation Number of pediatric patients simulated by trainee CNS Leukemia Other Total number of children simulated at affiliated institution for the reporting year: CNS: Leukemia: Other: Name of staff person responsible for pediatric service: Signature: topic1569.doc
  37. 37. SUPPLEMENT G. PEDIATRICS: REPORT B RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG For pediatric experience in an outside affiliated institution (copies to be retained by resident, affiliate, and primary institution) TO BE COMPLETED BY THE FACULTY SUPERVISOR AT THE AFFILIATED INSTITUTION. Name of Affiliated Institution City/State Name of Supervisor at Affiliate Signature TO BE COMPLETED BY THE PROGRAM DIRECTOR AT PRIMARY INSTITUTION. Program Number / Program Name City/State Program Director Name Signature TO BE COMPLETED BY THE RESIDENT (RESIDENTS ARE ALSO ENCOURAGED TO MAINTAIN A LIST OF SPECIFIC CASES). Resident Name Signature Time Period to be Covered by Log From: To: Pediatric Cases: # Simulated Leukemia Medulloblastoma CNS (Non-Medulloblastoma) Hodgkins’s Lymphoma Rhabdomyosarcoma / STS Ewing’s Sarcoma / Bone Tumor Neuroblastoma Wilms’ Tumor Other (specify): topic1569.doc
  38. 38. SUPPLEMENT G. BRACHYTHERAPY: REPORT A RRC FOR RADIATION ONCOLOGY AFFILIATED INSTITUTION REPORT: BRACHYTHERAPY TO BE COMPLETED BY THE AFFILIATED INSTITUTION. Affiliated Institution Date Number of Radiation Oncology residents assigned to the affiliated institution at any given time Does institution have an ACGME accredited radiation oncology residency program? List all residents assigned for brachytherapy rotations during the past calendar year: Dates -From To Include visiting trainees as well as residents in your program. Use additional sheets if necessary. Attach brachytherapy logs filled out by visiting residents. Resident Name Name of Resident’s Home Program Dates of rotation Number of procedures for which resident had primary responsibility Number of procedures observed (secondary responsibility) Interstitial Intracavitary Interstitial Intracavitary Total number of brachytherapy procedures at affiliated institution for reporting period: Interstitial: # Procedures / # Patients Intracavitary: # Procedures / # Patients Name of staff person responsible for brachytherapy service: Signature: topic1569.doc
  39. 39. SUPPLEMENT G. BRACHYTHERAPY: REPORT B RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG - For brachyteraphy experience in an outside affiliated institution (copies to be retained by resident, affiliate, and primary institution). TO BE COMPLETED BY THE FACULTY SUPERVISOR AT THE AFFILIATED INSTITUTION. Name of Affiliated Institution City/State Name of Supervisor at Affiliate Signature TO BE COMPLETED BY THE PROGRAM DIRECTOR AT PRIMARY INSTITUTION. Program Number / Program Name City/State Program Director Name Signature TO BE COMPLETED BY THE RESIDENT (RESIDENTS ARE ALSO ENCOURAGED TO MAINTAIN A LIST OF SPECIFIC CASES). Resident Name Signature Time Period to be Covered by Log From: To: TO BE COMPLETED BY THE ROTATING RESIDENT. BRACHYTHERAPY Primary Institution Outside Institution # Cases Performed # Cases Observed # LDR/HDR # Cases Performed # Cases Observed # LDR/ HDR INTRACAVITARY Number of Patients Number of Insertions Cervix / Uterus Endobronchial Esophagus / Bile Duct Other INTERSTITIAL (including seeds) Number of Patients Number of Implants Breast Soft Tissue Sarcoma Head & Neck Prostate GYN / Pelvis Other Surface Applications (moulds, plaque, Sr-90) Unsealed Sources (e.g. I-131 oral, P-32 colloid, Sr- 89, Sm-153, other) Endovascular Insertions topic1569.doc

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