Please make sure your data have been transferred to the ATC before submitting this form.

ATC
Advanced Technology QA Center
Digital Data Submission
Information Form
Protocol Sponsor / Number
Case Number
(Use number assigned
by Protocol Sponsor.
Use CR for credentialing:
dry-run/benchmark/phantom).
SUBMISSION TYPE
Submission
Category
  (select one)






 
See note
regarding
Rapid Review
Submission
Type
  (select one)





CONTACT INFORMATION
Institution Name
Institution RTOG #
      (if applicable)
Institution NSABP #
      (if applicable)
Institution GOG #
      (if applicable)
Patient Initials
Institution RTF #
      Look up RTF #
Institution NCI #
      

Personnel Involved with Protocol Patient
PhysicianPhysicistDosimetristResearch Associate
Name 
Phone 
Fax 
Email 

SUBMISSION DETAIL
Dose Prescription
(Protocol Specific)


Dose Delivered Via
















Dose Calculation
Heterogeneity Corrected
Heterogeneity Uncorrected
Submission Method
SFTP Login Used for Submission
Data Directory Name (for SFTP)
First Treatment Date
(Date of Implant)
ATC Digital Data
(Submission Date)
Date of CT Series


Radiation Treatment Planning System
Manufacturer:
TPS:
Software Version:
Dose Calc Algorithm:
Brachytherapy only:
Prescription dose for this patientGy in fractions.
If more than one fraction, time between fractions:
Number of catheters: . Source Strength:
Isotope Used: Manufacturer: Model:
Implant Technique:
(if applicable)
 



   Implant Dimensions:
(if applicable)
 
Length: cm
Width: cm
COMMENTS
Form completed by:
Date: