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									                   New-Additional Staff and Instrumentation Form
Included in this document are:

    1. Forms for new medical directors and technical directors
    2. Forms for adding medical and technical staff
    3. Forms to additional new equipment

Please complete all applicable forms.




Version 4.0 ICANL Accreditation Application                        1
Additional 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.
Version 4.0 ICANL Accreditation Application                                                                       2
Additional Forms (Updated April 2010)
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.

              copies of appropriate documentation such as:
              Provide
                        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      no
     If yes, specify responsibilities and to whom they are delegated:

    Does the medical director personally supervise stress testing     yes      no
     If yes, attach BLS/ACLS certification.


Version 4.0 ICANL Accreditation Application                                                                           3
Additional Forms (Updated April 2010)
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        Hours relevant
                                                                    Cat I, etc.          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:




Version 4.0 ICANL Accreditation Application                                                                    4
Additional Forms (Updated April 2010)
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 number
2.    Patient name
3.    Date of study
4.    Type of study
5.    Gamma or PET camera manufacturer, model

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




Version 4.0 ICANL Accreditation Application                                                                       5
Additional Forms (Updated April 2010)
                                              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:




Version 4.0 ICANL Accreditation Application                                                                           6
Additional Forms (Updated April 2010)
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:            Hours relevant to
                                                                 VOICE, etc.         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

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


Name:                           Signature:

Date:




Version 4.0 ICANL Accreditation Application                                                                    7
Additional Forms (Updated April 2010)
                                         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

Version 4.0 ICANL Accreditation Application                                                                       8
Additional Forms (Updated April 2010)
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      no
     If yes, attach BLS/ACLS certification.




Version 4.0 ICANL Accreditation Application                                                                           9
Additional Forms (Updated April 2010)
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        Hours relevant
                                                                   Cat I, etc.          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

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

Name:                                   Signature:

Date:




Version 4.0 ICANL Accreditation Application
10
Additional Forms (Updated April 2010)
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 number
7.    Patient name
8.    Date of study
9.    Type of study
10.   Gamma or PET camera manufacturer, model

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




Version 4.0 ICANL Accreditation Application
11
Additional Forms (Updated April 2010)
                                 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     no
Responsible for image acquisition and performance of procedures:       yes      no

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




Version 4.0 ICANL Accreditation Application
12
Additional Forms (Updated April 2010)
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:            Hours relevant to
                                                                 VOICE, etc.         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

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

Name:                                   Signature:

Date:




Version 4.0 ICANL Accreditation Application
13
Additional Forms (Updated April 2010)
                                   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                         #3
Manufacturer
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




Version 4.0 ICANL Accreditation Application
14
Additional Forms (Updated April 2010)

								
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