Please Note: This PSA should be completed by sites that have previously participated in RTOG 0625/ACRIN 6677.

Please submit in electronic format.

Contact 6686 protocol manager Bernadine Dunning (Ph: 215-574-3228 and/or E: ) for more information.

Name of Site:
Address:
Study Team
MRI Physician/Radiologist (Attach CV):
Address:
Telephone: / Fax: / E-mail:
ACRIN Research Associate/Coordinator:
Address:
Telephone: / Fax: / E-mail:
Lead MRI Technologist:
Address:
Telephone: / Fax: / E-mail:
MRI Technologist (Tech. responsible for the acquisition of the scans:
Address:
Telephone: / Fax: / E-mail:
MR Physicist:
Address:
Telephone: / Fax: / E-mail:
Primary Supporting Oncologist:
Address:
Telephone: / Fax: / E-mail:
Oncology RN/Coordinator:
Address:
Telephone: / Fax: / E-mail:

Information Systems Technology

Sites are required to submit MRI images in DICOM format to the ACRIN core laboratory. Sites are encouraged to transfer images using TRIAD software, provided by ACRIN for installation on a site’s PC. TRIAD collects image sets from a scanner’s computer or from the picture archiving communications system (PACS). TRIAD anonymizes, encrypts, and non-destructively compresses the images as they are transferred to the ACRIN image archive in Philadelphia. Sites may also use a secured file transfer protocol (sFTP) to submit images to a specified location on the ACRIN server; or they may submit images on a CD to the ACRIN Imaging Core Laboratory. Plain/hard copy films are not accepted.

Will your site grant the necessary firewall permissions to transfer electronic image files from a TRIAD server at your site to ACRIN’s image archive via the Internet? / Yes / No
Please indicate if your site has a PC available with the following specifications to support the TRIAD software:
·  Operating System Windows XP Pro, Windows 2000 Server SP4 and above, and Windows 2003 server
·  Intel P-III 1 GHz minimumprocessor
·  Access to the Internet: Internet Explorer
·  A 100 GB hard drive is preferred
·  At least 512 MB RAM
·  Ability to view PDF documents
·  Software utilities required to run image transmission software:
o  Windows Installer 3.1
o  Microsoft .NET framework 2.0
o  MDAC Type 2.8
o  MS SQL 2005 Express / Yes / No

Please contact the ACRIN TRIAD help desk to arrange for installation of TRIAD software prior to first accrual at or by phone at 215-940-8820.

Imaging Equipment

MRI Scanner Information:

Please provide the following information for all MRI scanners to be used this study.

Manufacturer / Model/ Magnet Strength / Is the scanner ACR accredited?
See note. / Accreditation expiration date(s)
Yes / No
Yes / No
Yes / No

Note: If the site does not have American College of Radiology (ACR) MR accreditation, an MR QA Questionnaire must be submitted with the PSA. The MR QA questionnaire can be found at www.acrin.org/6686_protocol.aspx and is also included on page 8 of this application.

Is your site able to perform the MRI scan acquisition parameters described in Appendix XIII of the protocol? / Yes / No

MRI Scanner Qualification

ACRIN qualification of the MRI scanner to be used on this study is also required prior to enrollment of study participants. This is separate from the ACR accreditation requirement noted above.
A test imaging submission consisting of all required advanced imaging series, performed per protocol specifications must be submitted for scanner qualification for advanced imaging.
Instructions for scanner qualification for ACRIN 6686 are available on the protocol-specific Web page (click on the “Imaging Materials” section) at www.acrin.org/6686_protocol.aspx or contact Jim Gimpel RT(R) (MR) at or 215-574-3238 for parameters and imaging instructions.

ACRIN Protocol Principal Investigator Confirmation

I, (Name of Protocol Principal Investigator*) have reviewed and agree with the information contained in this application.

Signature (electronic signature is acceptable):

Date:

E-mail:

Application Submission Information:

Please e-mail the completed application to: . (Preferred delivery)

To mail or fax the application and materials:

American College of Radiology

Attn: ACRIN 6686 PSA

Diagnostic Administration

1818 Market Street, Suite 1600

Philadelphia, PA. 19103-3604

Fax: 215-717-0936


MRI Quality Assurance Program Questionnaire

The following information is required for sites applying to participate in ACRIN 6686 that do not have ACR MRI accreditation.

Technologist Qualifications

§  Number of full-time technologists performing MRI scans:

§  Number of above technologists who are registered:

§  Number of above registered technologists with MRI certification:

Radiologist Qualifications

§  Number of board certified radiologists who interpret MRI scans:

o  Number of above radiologists who have at least 150 hours of CME over a three-year period:

§  Type of MRI related certifications or fellowships held by facility radiologists

§  Hours an MRI supervising radiologist is available in the MRI department daily:

§  Number of MRI body and musculoskeletal cases interpreted for the most recent calendar year:

o  Does the facility or department have dedicated readers for body and musculoskeletal cases? Yes No

o  If yes, how many?

§  Number of MRI neuro cases interpreted for the most recent calendar year:

o  Does the facility or department have a dedicated neuro reader? Yes No

o  If yes, how many?

§  Please list any other MRI sub-specialties for which the department has dedicated readers:

Medical Physicist

§  Identify medical physicist who oversees the quality control program and attach CV:

§  Is medical physicist certified by the American Board of Radiology in the following sub-fields?

Diagnostic Radiological Physics Yes No

Radiological Physics Yes No

Quality Assurance Program

§  Does your institution have a Quality Assurance program in place that outlines policies and procedures related to quality, patient education, infection control, and safety?

Yes (attach copy if applicable) No

§  Does your facility maintain documentation on site of any results of an appropriateness/outcomes analysis and actions taken to correct any deficiencies?

Yes No

MR Equipment Quality Control

Does all equipment meet state and federal requirements? Yes No

Does facility have regularly scheduled preventive maintenance checks performed and documented by a qualified service engineer on a regular basis? Yes No

Does facility site maintain documentation of services performed to correct any system deficiencies? Yes No

Please complete the following regarding MR equipment performance checks:

Checked Annually by Medical Physicist?
Yes / No
(If no, provide frequency of inspection)
Magnetic Field Homogeneity
Slice Position Accuracy
Slice Thickness Accuracy
Radiofrequency Coil Checks
Inter-Slice Radiofrequency Interference
Soft-Copy Displays (Monitors)
Checked Weekly by Technologist?
Yes / No
(If no, provide frequency of inspection)
Center frequency
Table Positioning
Setup and Scanning
Geometric Accuracy
High-Contrast Resolution
Low-Contrast Resolution
Artifact Analysis
Film Quality Control
Visual Checklist

Publications

§  Attach a list of recent MRI related publications, if any, authored by radiologists who interpret MRI cases.

Name and title of individual completing this questionnaire:

Date:

1

Version Date: 10/6/2009 R1