Other Cardiovascular
Testing Supplement (Add On)

(e.g., myocardial sympathetic innervation imaging (i.e.,Adreview),
cardiac molecular imaging, cardiac shunt studies, first pass, venogram/thrombus localization)

An additional testing area (or areas) may be added to a facility’s current accreditation at any time during the three-year accreditation cycle. Accreditation is granted only for the specific testing areas for which a facility has applied and submitted an application. Though facilities may be performing other testing in the facility, those areas are not covered under the accreditation until an application for the specific testing type is submitted and granted accreditation.

Please answer all questions, required attachments will be indicated by the symbol. Case studies requirements are listed on the last page. (If new staff is being added, please also submit the required staff forms.)

Name of institution (as listed in the Accreditation Agreement):
(This institution name will be tracked in the IAC database and will receive all IAC correspondence)

Application #:

Department:

Street address 1:

Street address 2:

City:State: Zip code:

Location of Nuclear Cardiologyfacility:

IAC Nuclear/PET Other Cardiovascular Testing Supplement – Add On 1

Reviewed 6/2015

Hospital

Private office

Free-standing imaging center

Independent facility

Other (please specify):

IAC Nuclear/PET Other Cardiovascular Testing Supplement – Add On 1

Reviewed 6/2015

1)Indicate the annual volume this site performs in the following nuclear cardiology testing area(Applicable Standard: 2.1B):
Other Cardiovascular (cardiac molecular imaging, cardiac shunt, first pass, venogram/thrombus localization):

Please submit a copy of the facility-specific Other Cardiovascular protocol(s) that includes: indications, patient prep, radiopharmaceutical, camera set up, patient position, acquisition parameters, processing instructions, and display/labeling information. (Applicable Standard: 2.4B):

EQUIPMENT PROTOCOLS

Please submit a copy of the facility-specific Intrinsic or Extrinsic Uniformity (flood) protocol(s): Images/documentation (hard copy or electronic) of the most recent uniformity test for all cameras must submitted with the case study materials. (Applicable Standard: 1.3.1.2B)

(Only submit if new equipment is being added.)

Please submit a copy of the facility-specific Spatial Resolution/Linearity (bar phantom) protocol(s): Images/documentation (hard copy or electronic) of the most recent resolution test for all cameras must submitted with the case study materials. (Applicable Standard: 1.3.1.3B)

(Only submit if new equipment is being added.)

Please submit a copy of the facility-specific Center of Rotation (COR) protocol(s): Images/documentation (hard copy or electronic) of the most recent resolution test for all cameras must submitted with the case study materials. (Applicable Standard: 1.3.1.4B)
(Only submit if new equipment is being added.)

Please submit a copy of the Preventative Maintenance documentation (must be within six months of submission) for all cameras: (Applicable Standard: 1.3.1.6B)
(Only submit if new equipment is being added.)

CASE STUDIES:

OTHER CARDIOVASCULAR:

A total of four other cardiovascular case studies performed within one year prior to the submission date are required (only two other cardiovascular cases will be required if the facility is seeking accreditation in an additional Nuclear Cardiology section). Only one case may be normal.

For more details on case study requirements, visit intersocietal.org/nuclear/seeking/case_studies_NC.htm.

IAC Nuclear/PET Other Cardiovascular Testing Supplement – Add On 1

Reviewed 6/2015