QARC

QARC
QUALITY ASSURANCE
CheckMate 73L (CA20973L)
Building B, Suite 201
640 George Washington Highway
Lincoln, RI 02865-4207
REVIEW CENTER Phone (401) 753-7600
Fax: (401) 753-7601
RT-2 Form www.QARC.org

At completion of radiotherapy submit this form with all radiotherapy data required.

Fields In Red Are Required

Subject #: __________________________________________________________________________________________________
Radiotherapy Dept: __________________________________________________________________ Site #: _________________
Physicist/ Dosimetrist: _______________________________________________________________________________________
Radiation Oncologist Name: __________________________________________________________________________________
Radiation Oncologist Email: __________________________________________________________________________________

List Names Of Target Volumes Corresponding To Those On RT-1 Forms

Name of Target Volume (i.e. PTV)
Date of First Treatment to the Target Volume
Number of Treatments
Date of Last Treatment
Total Dose To Target Volume
Treatment Interruptions (List Planned Interruptions, Including Holidays)
From: To: Reason:

From: To: Reason:

From: To: Reason:

From: To: Reason:

From: To: Reason:

Off Protocol Therapy

Date: Reason:

Discontinued Radiotherapy
Date: Reason:

Discontinued Study
Date: Reason:

This form was completed by:

Please save and submit to QARC via QARC SUBMIT
OR
Print Name: Email as an attachment to CheckMate73L@qarc.org

Date: Please do not submit duplicate copies

Email:

Version: 1.0 (12 JUN 2019)