intracavitary

THE RESIDENCY REVIEW COMMITTEE FOR RADIATION ONCOLOGY515 N State, Ste 2000, Chicago, IL 60654 (312) 755-5000 www.acgme.org

FOR CONTINUED ACCREDITATION

GENERAL INSTRUCTIONS

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the Program Information Form (PIF) is being completed for a currently accredited program, follow the provided instructions to create the correct form. Go to the Accreditation Data System found on the ACGME home page (www.acgme.org) under Data Collection Systems. Using your previously assigned User ID and password, proceed to the PIF Preparation section on the left hand menu and update the Common PIF data. Most data are updated through annual updates, but some information is required at the time of site visit only. Once the data entry is complete, select Generate PIF to review and print the Common PIF (PDF). Pages will be numbered consecutively in the bottom center of each page.

Once the Common PIF is complete, proceed to the appropriate Residency Review Committee webpage to retrieve the Specialty Specific PIF for CONTINUED ACCREDITATION. Once the forms are complete, enter page numbers for the Continued PIF in the bottom center for each page that consecutively follows the Common PIF numbering, combine the Common PIF and the Continued Accreditation PIF and complete the Table of Contents (found with the Specialty Specific PIF instructions). After completing the PIF/documents, make four copies. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding. Mail one set of the completed forms to the site visitor at least 14 days before the site visit. The remaining three sets should be provided to the site visitor on the day of the visit.

The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution.

Review the Program Requirements for Residency Education in Radiation Oncology. The Program Requirements and the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org):

For questions regarding:

-the completion of the form (content), contact the Accreditation Administrator

-the Accreditation Data System, email [email protected].

For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

Radiation Oncology Continued Accreditation PIF i

http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

http://www.acgme.org/

Please have the following documents available for the site visitor:

References to Common Program and Institutional Requirements are in parentheses.

1. Policy for supervision of residents (addressing resident responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR IV.A.4)

2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j)

3. Moonlighting policy (CPR II.A.4.j; CPR VI.F)

4. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC)

5. Overall educational goals for the program (CPR IV.A.1)

6. Competency-based goals and objectives for each assignment at each educational level (CPR IV.A.2)

7. Current Program Letters of Agreement (PLAs) (CPR I.B.1)

8. Files of current residents who have transferred into the program, if applicable (including documentation of previous experiences and summative competency-based performance evaluations) (CPR III.C.1)

9. Evaluations of residents at the completion of each assignment (CPR V.A.1.a)

10. Evaluations showing use of multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(2))

11. Documentation of residents’ semiannual evaluations of performance with feedback (CPR II.A.4.g; V.A.1.b.(4))

12. Final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2)

13. Completed annual written confidential evaluations of faculty by the residents (CPR V.B. 3)

14. Completed annual written confidential evaluations of the program by the residents (CPR V.C.1.d.(1))

15. Completed annual written confidential evaluations of the program by the faculty (CPR V.C.1.d.(1))

16. Documentation of program evaluation and written improvement plan (CPR V.C)

17. Documentation of resident duty hours (CPR II.A.4.j; VI.D.1-3)

18. Files of current residents and most recent program graduates

Added documents for some programs:

1. Documentation of conference attendance

2. Single RRC Sponsors only:

a) Copy of the resident contract with the pertinent items from the Institutional Requirements and Master Affiliation Agreements (IR II.D.4)

b) Institutional policies and procedures for residents’ duty hours and work environment (CPR II.A.4.j; CPR VI.C; IR II.D.4.i; IR III.B.3)

c) Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A)

Radiation Oncology Continued Accreditation PIF ii

d) Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e; IR III.B.7)

Radiation Oncology Continued Accreditation PIF iii


10 Digit ACGME Program I.D. #:Program Name:

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the bottom center. Report this pagination in the Table of Contents and submit this cover page with the completed PIF.

Common PIF Page(s)Accreditation InformationParticipating Sites

Sponsoring Institution/Single or Limited Residency Institution (If applicable)Faculty/Teaching Staff

Program Director InformationPhysician Faculty RosterFaculty Curriculum VitaeNon Physician Faculty Roster

Resident AppointmentsNumber of PositionsActively Enrolled Residents (if applicable)Aggregated Data on Residents Completing or Leaving the Program for the last 3 years (if applicable)Residents Completing Program in the Last 3 years (if applicable)Transferred, Withdrawn, and Dismissed Residents (if applicable)

EvaluationResident Duty Hours

Specialty Specific PIF Page(s)Patient CareMedical Knowledge

RotationsConferencesClinical ProgramOutside RotationsDidactic Program

Practice-based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-based PracticeSpace and EquipmentSummary of Resident Experience LogsNarrative Description of Training ProgramResearchResident PresentationsFaculty PublicationsAppendix A - Affiliation/integration agreements

Radiation Oncology Continued Accreditation PIF 1

Specialty Specific PIF Page(s)Appendix B - Reporting Forms for Pediatric Radiation Oncology/ Brachytherapy Outside Rotations

Pediatric Radiation Oncology - Resident Experience LogPediatric Radiation Oncology - Non-integrated Site ReportBrachytherapy - Resident Experience LogBrachytherapy - Non-integrated Site Report

Appendix C - Goals and ObjectivesAppendix D - Resident Logs



SPECIALTY SPECIFIC PROGRAM INFORMATION FORM

I. PATIENT CARE

Inclusive Dates for most recent 12-month period FROM: TO:

RADIATION ONCOLOGYSite #1

(Primary)Site #2 Site #3 Site #4 Site #5

Total patients seen in consultationTotal cases irradiated with external RT

NewRetreated:

Number of BrachytherapyProcedures (PR) / Patients (P)

PR P PR P PR P PR P PR P

IntracavitaryInterstitial

Unsealed radionuclide proceduresFollow-up visits% of follow-up visits seen by residentsTypical number of FTE clinical faculty at each siteTypical distribution of residents on clinical radiation oncology rotations at a given timeNumber of residents on research or other clinical (non-radiation oncology) rotations at a given time

NUMBER AND TYPES OF NEOPLASMS SIMULATED

Site #1(Primary)

Site #2 Site #3 Site #4 Site #5

PrimaryBrain, Pituitary, Spinal CordHead and NeckLung and TracheaBreastGastrointestinalGenitourinaryGynecologyLymphomas, Leukemia, MyelomaBone and Soft TissueSkinPediatric (under 18 years)


Unknown primaryBenignOther

Secondary (Metastases)Does Department have a tumor registry?Does Hospital have a tumor registry?Does Department maintain an active follow-up system?

Number and Types of Neoplasms Seen in Consultation

Site #1(Primary)


PrimaryBrain, Pituitary, Spinal CordHead and NeckLung and TracheaBreastGastrointestinalGenitourinaryGynecologyLymphomas, leukemia, myelomaBone and soft tissueSkinPediatric (under 18 years)Unknown primaryBenignOther

Secondary (Metastases)


II. MEDICAL KNOWLEDGE

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 OncologyMedical Oncology: AdultMedical Oncology: PediatricPathologyPhysics Didactic CourseRadiation and Cancer Didactic CourseMedical Statistics Didactic CourseDiagnostic ImagingOthers (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.

1. Intradepartmental

Is resident attendance required?

Number of conferences held

annuallyYES ( ) 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

annuallyYES ( ) NO ( )YES ( ) NO ( )YES ( ) NO ( )YES ( ) NO ( )

C. Clinical Program

1. Do the residents receive at least 36 months in clinical radiation oncology?

2. 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.

3. 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.

4. Describe the residents’ experience in diagnostic imaging, or an equivalent experience in the form of conferences and tumor boards.

5. Describe the residents’ educational experience in pain management and palliative care.

6. 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?

7. 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.


8. 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.

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.

9. How is the optimal distribution of radiation dose taught?


10. How are residents taught about calibration and monitoring of equipment and radiation safety procedures, such as handling of radionuclides?

11. Describe resident participation in follow-up clinics.

12. Do residents or faculty ever see patients in consultation alone? If so, what percent are seen alone by residents? By faculty?

13. Describe resident participation in the department’s quality assurance program, such as chart rounds and port film checks.

14. 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.

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.

2. If residents are sent for additional experience to another site where residents from other programs are also rotating, then provide the information as requested (Appendix B).


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.

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 integrated or non-integrated sites 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.

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.


III. PRACTICE-BASED LEARNING AND IMPROVEMENT

Examples of Learning Activities: didactic lecture, assigned reading, seminar, self-directed learning module, conference, small group discussion, workshop, online module, journal club, project, case discussion, one-on-one mentoring, or other examples of learning activities.

1. Describe one learning activity in which residents engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; identify and perform appropriate learning activities to achieve self-identified goals (life-long learning).

Limit your response to 400 words.

2. Describe one example of a learning activity in which residents engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include:

a) locating informationb) using information technologyc) appraising informationd) assimilating evidence information (from scientific studies)e) applying information to patient care


3. Give one example and the outcome of a planned quality improvement activity or project in which at least one resident participated in the past year that required the resident to demonstrate an ability to analyze, improve and change practice or patient care. Describe planning, implementation, evaluation and provisions of faculty support and supervision that guided this process.


4. Describe how residents:

a) develop teaching skills necessary to educate patients, families, students, and other residents;b) teach patients, families, and others; and c) receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is

used to evaluate these skills have it available for review by the site visitor.)



IV. INTERPERSONAL AND COMMUNICATION SKILLS

1. Describe one learning activity in which residents develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with physicians, other health professionals, and health related agencies.


2. Describe one learning activity in which residents develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities.


3. Explain (a) how the completion of comprehensive, timely and legible medical records is monitored and evaluated, and (b) the mechanism for providing residents feedback on their ability to competently maintain medical records.



V. PROFESSIONALISM

1. Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles.


2. How does the program promote professional behavior by the residents and faculty?


3. How are lapses in these behaviors addressed?



VI. SYSTEMS-BASED PRACTICE

1. Describe the learning activity(ies) through which residents achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality.


2. Describe an activity that fulfills the requirement for experiential learning in identifying system errors.



VII. SPACE AND EQUIPMENT

Site #1 (Primary)


Allocation of Space In Radiation Oncology (Specify number of each)Examining RoomsResident Work Space (Offices)Staff Offices

ClinicalPhysicsBiology

Conference RoomsTreatment Planning RoomsTreatment Aid Construction RoomLaboratories:

Radiobiology / Cancer BiologyPhysics

LibraryOther

External Beam Radiotherapy Equipment (Specify number of each)Kilovoltage Units (Superficial / Contact Therapy)Megavoltage UnitsUnits with Electron CapabilityIntraoperative RT UnitsHyperthermia UnitsGamma Knife UnitsLINAC Radiosurgery UnitsOther (Specify)Planning Equipment (Specify number of each)

Fluoroscopic SimulatorsCT SimulatorsTreatment Planning Computer / Workstation2-Dimensional Planning Computers3-Dimensional Planning ComputersIMRT Capability


Site #1 (Primary)


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)

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


VIII. 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

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Total Simulated Average

#simulate

d/ 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."


B. Summary experience should be included for all residents who have completed the program during the last 3 years. (Use 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 Ben

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Bre

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Total Simulated Average

#simulate

d/ 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." YES ( ) NO ( )IX. NARRATIVE DESCRIPTION OF TRAINING PROGRAM


1. What other accredited residency programs are conducted by the primary site?

2. Are there staff vacancies? If so, what is being done to fill them?

3. Does the resident evaluation of the faculty include knowledge base, teaching skill, mentoring ability, delegation or of responsibility and stimulus to do investigation?

4. 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?.............................................................................................( ) YES ( ) NO

5. Describe any additional training positions (e.g., clinical or research fellows who have completed training in an accredited radiation oncology residency program):

6. Do all residents have one year of postgraduate clinical training before beginning training in radiation oncology? ( ) YES ( ) NO

7. What is the ratio of residents to staff?

8. Do you provide non-integrated or any other training for trainees from other sites*?( ) YES ( ) NO

If YES, provide names of other sites, describe the rotations and specify the number of resident-months in a given year allocated to residents rotating from other sites.

Name of Other Sites Describe the RotationsNumber of Resident-Months

in a Given Year


If the non-integrated site is utilized for pediatric or brachytherapy experience, please attach the designated resident experience forms as Supplement F.


X. RESEARCH

1. Describe briefly the research space and important special research facilities.

2. What opportunities currently exist in the department for resident initiated research?

3. Is a resident research project required by the program? .......................................( ) YES ( ) NO

4. Does the department provide funding to residents to attend national meetings? . .( ) YES ( ) NO

a) How is it allocated?

5. List research programs (not more than ten) being conducted by faculty members, particularly those in which residents participate.


XI. RESIDENT PRESENTATIONS

List resident presentations at local, regional, or national scientific meetings which have resulted from resident involvement in research.


XII. FACULTY PUBLICATIONS

List publications from the last five years by all the faculty. 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.

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 oncologyA. Peer reviewed articlesB. Non-peer reviewed articles (e.g., subject reviews, book chapters)C. Abstracts

II. Publications with principal emphasis on physicsA. Peer reviewed articlesB. Non-peer reviewed articles (e.g., subject reviews, book chapters)C. Abstracts

III. Publications with principal emphasis on radiobiologyA. Peer reviewed articlesB. Non-peer reviewed articles (e.g., subject reviews, book chapters)C. Abstracts

DO NOT INCLUDE REPRINTS.


APPENDIX A - INTEGRATION AGREEMENTS

Attach integration agreements for all sites listed in the Common PIF. 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.

Integration: An site 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 site, b) determines all rotations and assignments of residents, and c) is responsible for the overall conduct of the educational program in the integrated site. There must be a written agreement between the sponsoring institution and the integrated site stating that these provisions are in effect. Rotations to integrated sites are not limited in duration.

Non-integration: The program may establish a non-integrated relationship with another site for the purpose of limited rotations. Rotations to non-integrated sites may not exceed 6 months.


APPENDIX B - REPORTING FORMS FOR PEDIATRIC RADIATION ONCOLOGY/ BRACHYTHERAPY OUTSIDE ROTATIONS (ANY AFFILIATION OUTSIDE THE PARENT OR INTEGRATED SITE)

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 (Non-integrated Site 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.

PEDIATRIC RADIATION ONCOLOGY - RESIDENT EXPERIENCE LOG

For pediatric experience in an outside non-integrated site (copies to be retained by resident, affiliate, and primary site)

TO BE COMPLETED BY THE FACULTY SUPERVISOR AT THE NON-INTEGRATED SITE.Name of Non-integrated Site City/StateName of Supervisor at Affiliate Signature

TO BE COMPLETED BY THE PROGRAM DIRECTOR AT PRIMARY SITE.Program Number / Program Name City/StateProgram Director Name Signature

TO BE COMPLETED BY THE RESIDENT (RESIDENTS ARE ALSO ENCOURAGED TO MAINTAIN A LIST OF SPECIFIC CASES).Resident Name SignatureTime Period to be Covered by Log From: To:

Pediatric Cases: # SimulatedLeukemiaMedulloblastomaCNS (Non-Medulloblastoma)Hodgkin’s LymphomaRhabdomyosarcoma / STSEwing’s Sarcoma / Bone TumorNeuroblastomaWilms’ Tumor


Other (specify):


PEDIATRIC RADIATION ONCOLOGY - NON-INTEGRATED SITE REPORT

TO BE COMPLETED BY THE NON-INTEGRATED SITE.

Non-integrated Site DateNumber of Radiation Oncology residents assigned to the non-integrated site at any given timeDoes site 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 NameName of Resident’s Home

ProgramDates of Rotation

Number of pediatric patients simulated by traineeCNS Leukemia Other

Total number of children simulated at non-integrated site for the reporting year:

CNS: Leukemia: Other:

Name of staff person responsible for pediatric service:

Signature:


BRACHYTHERAPY - RESIDENT EXPERIENCE LOG - For brachytherapy experience in an outside non-integrated site (copies to be retained by resident, affiliate, and primary site).

TO BE COMPLETED BY THE FACULTY SUPERVISOR AT THE NON-INTEGRATED SITE.Name of Non-integrated Site City/StateName of Supervisor at Affiliate

Signature

TO BE COMPLETED BY THE PROGRAM DIRECTOR AT PRIMARY SITE.Program Number / Program Name City/StateProgram Director Name Signature

TO BE COMPLETED BY THE RESIDENT (RESIDENTS ARE ALSO ENCOURAGED TO MAINTAIN A LIST OF SPECIFIC CASES).Resident Name SignatureTime Period to be Covered by Log From: To:

TO BE COMPLETED BY THE ROTATING RESIDENT.

BRACHYTHERAPY

Primary Site Outside Site

# Cases Performed

# Cases Observed # LDR/HDR

# Cases Performed

# Cases Observed

# LDR/HDR

INTRACAVITARY

Number of PatientsNumber of InsertionsCervix / UterusEndobronchialEsophagus / Bile DuctOther

INTERSTITIAL (including seeds)

Number of PatientsNumber of ImplantsBreastSoft Tissue SarcomaHead & NeckProstateGYN / 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


BRACHYTHERAPY - NON-INTEGRATED SITE REPORT

TO BE COMPLETED BY THE NON-INTEGRATED SITE.

Non-Integrated Site DateNumber of Radiation Oncology residents assigned to the non-integrated site at any given timeDoes site 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 NameName of Resident’s

Home ProgramDates 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 non-integrated site for reporting period:

Interstitial:# Procedures

/ # Patients

Intracavitary:

# Procedures

/ # Patients

Name of staff person responsible for brachytherapy service:

Signature:


APPENDIX C - GOALS AND OBJECTIVES

Attach a sample of the goals and objectives for one assignment


APPENDIX D - RESIDENT LOGS

Please attach logs for 1) current residents and for 2) the most recent resident graduates (include 4 years of experience)


intracavitary

Documents

spinal cord head

peer reviewed articles

formal teaching hours

past calendar year

time spent equals

residents duty hours

residency review committee

staff person responsible