New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

PO Box 358

Trenton, NJ 08625-0358

ANNUAL REPORT OF MEGAVOLTAGE RADIATION UNIT

INSTRUCTIONS:

Please complete all questions and submit to above address by March 31.
Reporting Year

FOR STATE USE ONLY
ID Number
I. IDENTIFICATION
Name of Facility Submitting Report

Facility ID Number

Street Address

Location of Megavoltage Unit (if different from Submitting Address)

City	State	Zip Code

City	State	Zip Code

II. TYPE OF MEGAVOLTAGE
Energy
Photon
Electron
III. PERSONNEL OPERATIONS DATA
Operator Occupation (Do NOT Provide Names)	Personnel FTE1
a.	Radiation Oncologist 2
b.	Radiological Physicist 2
c.	Radiation Therapist 2
d.	Registered Professional Nurse 2
e.	Other (specify):
IV. UTILIZATION
Category	Linear #1	Linear #2	Linear #3
1.	Types of patients treated 2

a.	New Patients 3
b.	Retreated Patients
TOTAL PATIENTS
2.	Number of patient visits4

a.	New Patients
b.	Retreated Patients
TOTAL VISITS

ANNUAL REPORT OF MEGAVOLTAGE RADIATION UNIT

(Continued)

Name of Facility Submitting Report

Facility ID Number

IV. UTILIZATION, Continued
Category	Linear #1	Linear #2	Linear #3
3.	Number of Treatments (ports) 5

a.	New Patient Treatments (ports)
b.	Retreated Patient Treatments (ports)
TOTAL TREATMENTS
4.	Number of patients treated by electron beam

a.	New Patients3
b.	Retreated Patients
c.	TOTAL
5.	Number of brachytherapy patients:
V. TREATMENT PLANNING 2
1.	Does your facility have a simulator? Yes No
2.	If “No,” what other means of treatment planning is used?
3.	Is your megavoltage unit used for simulation purposes? Yes No
4.	If “Yes,” how many hours was it used during the year?
5.	Number of patients simulated at your facility:
a.	Simulator:
b.	Other:

Name

Title

Department

Telephone Number

Signature	Date

Footnotes:

1	One full-time equivalent (FTE) is to be considered equal to a 5-day, 40-hour week or 2080 hours per year. For fractional Equivalents, use 2080 as a base.

2	Required by N.J.A.C. 8:43A-30 and N.J.A.C. 8:43G.

3	A patient who has never before received radiation therapy or a returning patient with a second primary cancer (at a different site) which has not been previously treated.

4	Number of times a patient reports to the facility for treatment.

5	Application of radiation on one cancer site with one type of radiation modality.

CN-10

JUL 12	Page 1 of 2 Pages.

CN-10, Annual Report of Megavoltage Radiation Unit

CN-10, MEgavoltage, radiation, annual report

EWhite

2008-03-26

NJDOH