GYNECOLOGICAL BRACHYTHERAPY PROTOCOL COMPLIANCE FORM

This questionnaire is intended to evaluate your understanding of the protocol. If there are any
questions please contact the IROC Houston at (713) 745-8989 or IROCHouston@mdanderson.org

Institution Name:
RTF# * protocol# *   RTOG   GOG   ANZGOG   Taco
Patient Initials: *   Study group patient Case #: *
  Name Phone number Email address
Oncologist: * * *
Physicist: * * *
Dosimetrist:
Data Manager:
External Beam:        
Start date of external beam (mm/dd/yyyy) : End date of external beam (mm/dd/yyyy) :  
Whole pelvis total dose: (Gy) Daily dose: Total fractions:  
Boost dose: (Gy)    
Brachytherapy:
Treatment type:     LDR   HDR   Nuclide:   CS137   Ir192   Other
Source Model:  
   
Insertion Start Date (mm/dd/yyyy) Diameter Ovoid Caps (cm) AR (Gy) AL (Gy) BR (Gy) BL (Gy) Rectum (Gy) Bladder (Gy) Vaginal Surface (Gy)
    Total Dose:
Magnification Factor
AP Film
Lat. Film
HDR Insertuons submit the following information:
• AP and lateral orthogonal films for all insertions.
• Treatment plans for all insertions.(i.e. isodose distributions, all calculations)
• Activity, dwell times, dwell positions.
LDR Insertuons submit the following information:
• AP and lateral orthogonal films for all insertions.
• Treatment plans for all insertions.(i.e. isodose distributions, all calculations)
Source loading for LDR implants:
Source Activity (mgRaeq) Total Hours (hrs.) Active Length (mm) Physical Length (mm) Spacer Length (mm) Source Activity Total Hours (hrs.) Active Length (mm) Physical Length (mm) Spacer Length (mm)
Oviods           Oviods          
1 1
2 2
Tandem           Tandem          
3 3
4 4
5 5
6 6
 
  Submit all material to:  
  Dosimetry  
  IROC Houston QA Center  
  8060 EL RIO St.  
  Houston, TX 77054  
 

 

* This is a required field.