New/Additional Staff and Instrumentation Form

New-Additional Staff and Instrumentation Form

Included in this document are:

1. Forms for new medical directors and technical directors2. Forms for adding medical and technical staff3. Forms to additional new equipment

Please complete all applicable forms.

Version 4.0 ICANL Accreditation Application 1Additional Forms (Updated April 2010)

Medical Director

All questions must be answered. (Do not submit curriculum vitae.)

Name: MD DO E-mail:

Physician Licensure:

State(s): Expiration date(s):

Enclose a copy of current medical license(s) for geographical areas related to this application.

Authorized user under NRC/state radioactive material license yes no If no, please explain

Education and Training Information (Do not include curriculum vitae.)

Medical education:Medical School: Year MD/DO degree:

Residency training:Institution: Location: Specialty: Dates: from to Number of months dedicated to nuclear cardiology:

Fellowship training: Institution: Location: Specialty: Dates: from to Number of months dedicated to nuclear cardiology:

Training and Experience of the Medical Director:

Certification in nuclear cardiology by the Certification Board of Nuclear Cardiology (CBNC).

Board certified (or Board eligible but within two years of finishing training) in cardiology and completion of a minimum of a 4 month formal training program in nuclear cardiology [Level 2 as outlined in the ACC/ASNC COCATS Training Guidelines (2006 revision)]. This requirement applies only to cardiologists who began their cardiology training in July 1995 or later.

Board certified in cardiology and training equivalent to Level 2 training, or at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 800 nuclear cardiology studies. This requirement applies only to cardiologists who began their cardiology training before July 1995.

Board certified (or Board eligible but within two years of finishing training) in nuclear medicine.

Board certified (or Board eligible but within two years of finishing training) in radiology with at least 4 months of nuclear cardiology training.


OR

Board certified (or Board eligible but within two years of finishing training) in radiology with special competence in nuclear medicine.

Board certified (or Board eligible but within 2 years of finishing training) in radiology and at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 800 nuclear cardiology studies.

OR

Board certified (or Board eligible but within 2 years of finishing training) in radiology with at least 4 months of nuclear medicine training with interpretation of at least 800 nuclear medicine procedures.

Board certified (or Board eligible but within two years of finishing training) in any other relevant medical specialty recognized by the American Board of Medical Specialties, American Osteopathic Association, Royal College of Physicians and Surgeons of Canada or Le College des Medicins du Quebec and at least one year (full time equivalent) of nuclear cardiology/nuclear medicine/PET practice experience with independent interpretation of at least 800 nuclear cardiology/nuclear medicine and/or PET procedures. If performing nuclear medicine therapies, independent performance of a least 20 nuclear medicine therapies required.

If training before 1995, 10 years of nuclear cardiology, nuclear medicine and/or PET practice with independent interpretation of at least 800 nuclear cardiology, nuclear medicine and/or PET studies within the past 10 years of which 200 cases must have been interpreted in the past two years.

Provide copies of appropriate documentation such as: CBNC certificate or Board certification certificate, or Residency/fellowship completion certificate if not board certified

Further Description of Experience of the Medical Director

Number of years of nuclear cardiology/medicine/PET experience: Number of years as Medical Director of this laboratory:

Medical Director Responsibilities:

The Medical Director is responsible for all nuclear services provided including quality control, radiation safety and the quality and appropriateness of care provided. yes no

The Medical Director is responsible for assuring compliance of medical and technical staff to the standards outlined in the ICANL Standards. yes no

The Medical Director assures compliance with all policies/procedures/protocols and reviews all manuals periodically as necessary (minimum every three years) or as new policies are introduced. yes no

The Medical Director provides active oversight of radiation safety within the facility as evidenced by membership on the institution’s radiation safety committee or periodic review of radiation safety issues and documentation (if no radiation safety committee). The radiation protection program content and implementation are reviewed at least annually. yes no

If “no” for any of the above four items, please explain:

The Medical Director delegates the above responsibilities to other personnel yes noIf yes, specify responsibilities and to whom they are delegated:

Does the medical director personally supervise stress testing yes noIf yes, attach BLS/ACLS certification.


Continuing Medical Education (CME):

Using the CME form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear medicine, list only the number of hours specifically related to nuclear medicine. If you have more CME to report than fits on this form, you do not have to list all CME once you have documented 15 hours of relevant CME credit within the past three years. (Documentation of earned CME credits must be on file and available for inspection. Do not submit any CME certificates or transcript lists.)

ICANL CME Form (must be completed) Medical Director

Course dates Course name CME type: AMA Cat I, etc.

Hours relevant to nuclear cardiology

Total number of CME hours directly related to nuclear medicine earned in the past three years:

Certification by the Medical Director

I certify that the information regarding my experience and involvement with the laboratory is accurate and current.

Name: Signature:

Date:


New Case Study Requirements

Facilities are required to submit two abnormal case studies from each interpreting physician being added to the application. The case studies may be from any area in which the laboratory is accredited. All cases, regardless of the type of accreditation requested, must be selected from the past 2 months. Each case must include a sufficient number of images (hard copy and/or digital) to support the final diagnosis, along with a signed copy of the final report. A copy of any worksheets and/or preliminary reports, if generated, should also be submitted.

Guidelines for Case Selection and Submission:

1. Case selection is not camera dependent. You may select cases from any camera in your laboratory.2. Both cases must be abnormal. 3. Label each case with the type of exam and type of hard copy being submitted (film, digital etc.).

Label all cases, including any disks and hard copy with the following information:

1. Site/location name and number2. Patient name3. Date of study4. Type of study5. Gamma or PET camera manufacturer, model

Note: All material submitted to the ICANL will be handled with strict confidentiality in accordance with HIPAA regulations.


Technical Director All questions must be answered. (Do not submit curriculum vitae.)

Name: Degree initials: E-mail address:

Education and Training Information

Nuclear Medicine Technologist Training:

Name of institution: Location: Dates: from to Certification: CNMT RT(N) State license NCT

Training and Experience of the Technical Director:

Check all that apply:

An appropriate credential in nuclear medicine technology (RT (N), CNMT and/or state license) Three years or more of clinical experience in nuclear medicine/nuclear cardiology Current BLS (Basic life Support) certification

Enclose a copy of current nuclear medicine technologist registration card/license and BLS certification card.

Further Description of Experience of the Technical Director:

Number of years of nuclear medicine/nuclear cardiology experience: Number of years as Technical Director of this laboratory:

Duties of the Technical Director

The Technical Director is responsible for the day-to-day operations of the laboratory. yes no The Technical Director assesses competency of technical staff on an annual basis. yes no

If “no” for any of 1.2.2 above, please explain:


Continuing Education (CE):

Using the CE form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear medicine or nuclear cardiology, list only the number of hours specifically related to nuclear medicine or nuclear cardiology. If you have more CE to report than fits on this form, you do not have to list all CE once you have documented 15 hours of relevant CE credit within the past three years. (Documentation of earned CE credits must be on file and available for inspection. Do not submit any CE certificates or transcript lists.)

ICANL CE Form (must be completed)Technical Director

Course dates Course name CE type: VOICE, etc.

Hours relevant to nuclear medicine/ cardiology

Total number of CE hours directly related to nuclear medicine/nuclear cardiology earned in the past three years:

Certification by the Technical Director


Name: Signature:

Date:


Interpreting Medical Staff

For each member of the medical staff interpreting studies in the laboratory, please provide the following information. All questions must be answered. (Do not submit curriculum vitae.)

Name: MD DO E-mail Address:

Physician Licensure:

State(s): Expiration date(s):

Enclose a copy of current medical license(s) for geographical areas related to this application.

Education and Training Information (do not include curriculum vitae)

Medical education:Medical School: Year MD/DO degree:

Residency training:Institution: Location: Specialty: Dates: from to Number of months dedicated to nuclear cardiology:

Fellowship training: Institution: Location: Specialty: Dates: from to Number of months dedicated to nuclear cardiology:

Training and Experience of the Medical Director:

Certification in nuclear cardiology by the Certification Board of Nuclear Cardiology (CBNC).

Board certified (or Board eligible but within two years of finishing training) in cardiology and completion of a minimum of a 4 month formal training program in nuclear cardiology [Level 2 as outlined in the ACC/ASNC COCATS Training Guidelines (2006 revision)]. This requirement applies only to cardiologists who began their cardiology training in July 1995 or later.

Board certified in cardiology and training equivalent to Level 2 training, or at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 800 nuclear cardiology studies. This requirement applies only to cardiologists who began their cardiology training before July 1995.

Board certified (or Board eligible but within two years of finishing training) in nuclear medicine.

Board certified (or Board eligible but within two years of finishing training) in radiology with at least 4 months of nuclear cardiology training.

OR


Board certified (or Board eligible but within two years of finishing training) in radiology with special competence in nuclear medicine.

Board certified (or Board eligible but within 2 years of finishing training) in radiology and at least one year (full time equivalent) of nuclear cardiology practice experience with independent interpretation of at least 800 nuclear cardiology studies.

OR

Board certified (or Board eligible but within 2 years of finishing training) in radiology with at least 4 months of nuclear medicine training with interpretation of at least 800 nuclear medicine procedures.

Board certified (or Board eligible but within two years of finishing training) in any other relevant medical specialty recognized by the American Board of Medical Specialties, American Osteopathic Association, Royal College of Physicians and Surgeons of Canada or Le College des Medicins du Quebec and at least one year (full-time equivalent) of nuclear cardiology/nuclear medicine/PET practice experience with independent interpretation of at least 800 nuclear cardiology/nuclear medicine and/or PET procedures. If performing nuclear medicine therapies, independent performance of a least 20 nuclear medicine therapies required.

If training before 1995, 10 years of nuclear cardiology, nuclear medicine and/or PET practice with independent interpretation of at least 800 nuclear cardiology, nuclear medicine and/or PET studies within the past 10 years of which 200 cases must have been interpreted in the past two years.

Provide copies of appropriate documentation such as: CBNC certificate or Board certification certificate, or Residency/fellowship completion certificate if not board certified

Further Description of Experience of the Interpreting Medical Staff: Number of years of nuclear cardiology/medicine/PET experience: Number of years as interpreting medical staff member of this laboratory:

Responsibilities of the Interpreting Medical Staff Member:

This interpreting medical staff member provides the final interpretation and report of the clinical nuclear cardiology studies. yes no If no, please explain:

Does the medical director personally supervise stress testing yes noIf yes, attach BLS/ACLS certification.


Continuing Medical Education (CME)

Using the CME form provided within this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear cardiology/medicine/PET, list only the number of hours specifically related to nuclear cardiology/medicine/PET. If you have more CME to report than fits on this form, you do not have to list all CME once you have documented 15 hours of relevant CME credit within the past three years. (Documentation of earned CME credits must be on file and available for inspection. Do not submit any CME certificates or transcript lists.)

ICANL CME Form (must be completed)Medical Staff

Course dates Course name CME type: AMA Cat I, etc.

Hours relevant to nuclear cardiology

Total number of CME hours directly related to nuclear cardiology/medicine/PET earned in the past three years (15 hours of AMA Cat I CME mandatory January 1, 2004):

Certification by the Interpreting Medical Staff


Name: Signature:

Date:


New Case Study Requirements

Facilities are required to submit two abnormal case studies from each interpreting physician being added to the application. The case studies may be from any area in which the laboratory is accredited. All cases, regardless of the type of accreditation requested, must be selected from the past 2 months. Each case must include a sufficient number of images (hard copy and/or digital) to support the final diagnosis, along with a signed copy of the final report. A copy of any worksheets and/or preliminary reports, if generated, should also be submitted.

Guidelines for Case Selection and Submission:

4. Case selection is not camera dependent. You may select cases from any camera in your laboratory.5. Both cases must be abnormal. 6. Label each case with the type of exam and type of hard copy being submitted (film, digital etc.).

Label all cases, including any disks and hard copy with the following information:

6. Site/location name and number7. Patient name8. Date of study9. Type of study10. Gamma or PET camera manufacturer, model

Note: All material submitted to the ICANL will be handled with strict confidentiality in accordance with HIPAA regulations.


Nuclear Medicine Technologist Staff

This section must be completed for each technical staff member, including all full- or part-time staff members. All questions must be answered. (Do not submit curriculum vitae.)

Name: Degree initials: E-mail address:

Education and Training Information (Do not include curriculum vitae) Nuclear Medicine Technologist Training:

Name of institution: Location: Dates: from to Certification: CNMT RT(N) State license NCT PET

Training and Experience of the Nuclear Medicine Technologist:

Check all that apply:

An appropriate credential in nuclear medicine technology (RT (N), CNMT and/or state license) Current BLS (Basic life support) certification (include copy of current BLS certification)

Enclose a copy of current nuclear medicine technologist registration card/license and BLS certification card. (Label Part I, attachment 9)

Further Description of Experience of the Nuclear Medicine Technologist:

Number of years of nuclear medicine/nuclear cardiology experience: Number of years as nuclear medicine technologist in this laboratory:

Responsibilities of the Nuclear Medicine Technologist:

Reports to the Technical Director: yes noResponsible for image acquisition and performance of procedures: yes no

If “no” to either of the above, please explain.


Continuing Medical Education (CE)

Using the CE form provided with this application, list relevant credits earned during the past three years. Where programs or courses cover more than nuclear medicine or nuclear cardiology, list only the number of hours specifically related to nuclear medicine or nuclear cardiology. If you have more CE to report than fits on this form, you do not have to list all CE once you have documented 15 hours of relevant CE credit within the past three years. (Documentation of earned CE credits must be on file and available for inspection. Do not submit any CE certificates or transcript lists.)

ICANL CE Form (must be completed) Technical Staff

Course dates Course name CE type: VOICE, etc.

Hours relevant to nuclear medicine/ cardiology

Total number of CE hours directly related to nuclear medicine/nuclear cardiology earned in the past three years:

Certification by the Technical Staff


Name: Signature:

Date:


Equipment and Instrumentation

For each imaging system, complete the table below. This form can be used to list three imaging systems. If more space is needed to list additional equipment use the separate “Additional Forms” file for additional instrumentation tables.

Instrumentation Table

Imaging Systems #1 #2 #3Manufacturer Model Year of manufacture SPECT or planar Number of detectors PET - Gamma or dedicated Full or partial ring Acquisition computer Processing computer Display computer Stationary or mobile Preventative maintenance


Documents

New/Additional Staff and Instrumentation Form