3DCRT Facility Questionnaire Form

The ATC Facility Questionnaire for 3DCRT protocols is available from the links below. This form may be submitted online or by downloading a Microsoft Word or PDF document, which may be filled in and submitted by e-mail, mail or FAX.

This form is for credentialing on ATC-supported protocols involving 3D Conformal Radiation Therapy.   A separate form is provided for IMRT credentialing.   Please note that this version of the Facility Questionnaire replaces all earlier versions.

  1. Online 3DCRT Facility Questionnaire  
    Please contact ITC (314-747-5415) for instructions and password.
  2. ATC 3DCRT Facility Questionnaire (DOC) file
    Use Microsoft Word (file format is Microsoft Word for Windows) to complete the form.  Completed Word files may either be printed and mailed or emailed to the ITC (see address below).
  3. 3DCRT Facility Questionnaire (PDF) file
    Use Adobe Acrobat Reader to print the form. Mail the completed form to the address shown below.
Please mail the completed form to
Image-guided Therapy QA Center
4511 Forest Park Avenue
Suite 200
St. Louis, MO 63108
Attn: Roxana Haynes
Completed forms may also be FAXed to
314-747-5423
Attn: Roxana Haynes
Completed Word documents should be emailed to
itc@wustl.edu.
Document maintained by Walter R. Bosch

Send email to: itc@wustl.edu
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