Initial Molecular Imaging Site Setup Questionnaire

Important: Please make sure to read all text in this document and answer all questions. We can’t move forward in the process of on-boarding your site until this questionnaire is completed.

Please be sure to print and sign and upload these attachments to this form at the bottom before submitting.

Form 1: Service Agreement Authorization

Form 2: Site Authorization Letterhead

Hospital Information

Main Hospital Name(Required)

Main Hospital Location(Required)

Main Hospital Phone(Required)

Website

Outside Dialing (8, 9, or N/A)

Internal Dialing from Heritage Coach

Please explain dialing procedures:

Key Contacts

Director of Imaging Services Name

First Last

Director of Imaging Services Work Phone

Director of Imaging Services Cell Phone

Director of Imaging Services Email

Manager of Imaging Services Name

First Last

Manager of Imaging Services Work Phone

Manager of Imaging Services Cell Phone

Manager of Imaging Services Email

Site Radiation Safety Officer Name

First Last

Site Radiation Safety Officer Work Phone

Site Radiation Safety Officer Cell Phone

Site Radiation Safety Officer Email

Reading Radiologist(s) Name/Group(Required)

Reading Radiologist(s) Work Phone

Reading Radiologist(s) Email

Additional Radiologists (if more than one)

Is there a radiologist available for consultation the entire time we are operating at your site?

Yes

Department Phone Numbers

RN Contact Phone

IV Help Phone

IT Director/Manager Phone

PACS Administrator Phone

Nuclear Medicine Phone

Diagnostic Imaging Main Phone

Diagnostic Imaging Scheduling Phone

Diagnostic Imaging Admitting/Check In Phone

Additional Notes about phone procedures

Additional contacts that would help us provide the best service

Emergency Procedures

Medical Emergency – Who to call

If hospital page – What to announce

Security/Police – Who to call

If hospital page – What to announce

Fire Emergency – Who to call

Additional emergency instructions/procedures

Authorized User (Very Important)

Important: Please identify the Authorized User (AU) for this site. If this site has a Radioactive Materials License, the individual should be listed there. If this site does not have a license but performs Molecular Imaging, please ask your reading radiologist who the AU is for this site. If you list an Authorized User below please send the active and current Radioactive Materials License they are listed on to us with this document. Site Letter of Authorization: It is a state requirement that we have on file a letter authorizing us to provide PET/CT or Nuclear Medicine imaging services at your location. This must be on the company letterhead and can be signed by anyone in senior management at the location of service. This will be in a separate attachment. Please return with this form. If you have not received this attachment please let us know.

Current Authorized User for this site(Required)

Coach/Truck Connectivity Information

Is there a Russell/Stoles power plug?

Yes

If yes, how far from the mobile coach is the connection?

Is there a water connection (standard hose) nearby?

Yes

If yes, how far is the water connection from mobile coach?

Is there a network (Ethernet) connection for the mobile coach?

Yes

If yes, how far is the network connection from mobile coach?

Is there a phone connection for the mobile coach?

Yes

If yes, what type of connection (Hubbell or standard jack) and how far away?

Facility Supplied Items

MAP/Diagram/Floor Plan: We need you to send us a map of the interior of your facility. This usually is a building diagram, schematic, or floor plan. A PDF is preferable. This is used to indicate various locations in the facility so that any technologist that works here can find their way around. It also is a requirement of the state. We will need a blank copy and a copy with the designated patient restroom indicated. The state/NRC requires that you provide a designated restroom to our patients during normal operating hours due to the patients urine being slightly radioactive. It is for exclusive use of our patients and is cleared at the end of the day before we depart. We will also need a diagram/map of the exterior area of the facility with the location of the Coach/Truck indicated.

Facility Supplied Items

Wheelchairs

Gowns

Blankets

Towels

Scrubs

Oxygen tanks/regulators

Sheets

Pillowcases

Wash Clothes

Dirty Linen Bags

Are these items notated on facility map?

Yes

Is there an available restroom for our technologists to use separate from the patient designated restroom?

Yes

Have you notated the following locations on the facility map?

Where to bring a patient in distress

Where garbage is left at end of day

Patient reception and waiting area

Where patient paperwork is turned in

Where dirty linen is left at end of day

Where full sharps containers are left

Where patient paperwork is picked up

IT and PACS Information

IT and PACS information will be gathered by our IT team. Please give us a good contact.

PACS Contact

IT Contact

Sedation

Not offered due to limitations of mobile environment. Normally we allow any patient to take oral medication for anxiety/claustrophobia if it has been prescribed by their provider and is not contraindicated by scan. Please let us know if this presents a problem.

Any concerns with our sedation policy?

Patient Prep Protocols

Nuclear Medicine: We will provide the reading radiologist(s) our standard protocols to review and approve.

PET/CT – Please indicate your preference for PET/CT prep protocols

We can supply you with our normal prep protocols

Please provide us with your radiologist approved normal and diabetic patient prep protocols

Additional notes about prep protocols

Imaging Protocols

We use standard PET/CT and Nuclear Medicine protocols within the manufacturers guidelines that are the same or very similar at all our sites. Protocols for Nuclear Medicine will be available for review to the reading radiologist(s) and some adjustments can be made if requested. Note: Nuclear Medicine Image sets per protocol will be discussed during the protocol review process.

What are the normal PET/CT image sets currently sent to the PACS system?

Staff Orientation

Are there any staff orientation requirements for Heritage Imaging personnel? If there are please give details and time required

ID Badge

If needed what is the process for obtaining an ID badge?

Holidays Observed

Standard Holidays: Thanksgiving Day, Dec 25th, Jan 1st, Memorial Day, July 4th, Labor Day

Please list any additional holidays that this facility observes

Additional Information

If there is any other information that we may need in order to better serve you and our patients, please provide it below

Required Attachments

Attachments you need to send with this document: Interior and exterior maps blank copies and copies with everything indicated in the document Filled out and signed Site Authorization Letter on company letterhead Qualified Authorized User (AU) that is preferably on an active and current Radioactive Materials License The Radioactive Materials License where the AU is listed

File(Required)

Drop files here or

Max. file size: 32 MB.

Hospital Information

Key Contacts

Department Phone Numbers

Emergency Procedures

Authorized User (Very Important)

Coach/Truck Connectivity Information

Facility Supplied Items

IT and PACS Information

Sedation

Patient Prep Protocols

Imaging Protocols

Staff Orientation

ID Badge

Holidays Observed

Additional Information

Required Attachments

Site Map

Contact Us

Heritage Imaging (Mobile MRI, Mobile PET, Mobile CT)