SRS Registry Interest Form

Please provide your contact information and site details below.

Question Title

* 1. Contact Information

Name

Organization Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Which devices are used at your center for cranial SRS treatment?

Accuray CyberKnife

Brainlab Novalis TrueBeam STx

Brainlab Novalis Tx

Elekta Leksell Gamma Knife

Elekta LINAC Axesse

Elekta LINAC Synergy-S

Elekta LINAC Versa HD

Varian LINAC Clinac

Varian LINAC Edge

Varian LINAC Halcyon

Varian LINAC Trilogy

Varian LINAC TrueBeam

Varian LINAC VitalBeam

Other (please specify)

Question Title

* 3. Which treatment planning systems are used by your center for planning cranial SRS cases?

Accuray Precision (formerly MultiPlan)

Brainlab Elements Cranial SRS

Brainlab Elements Multiple Mets SRS

Brainlab iPlan RT Dose

Elekta Leksell GammaPlan

Elekta Monaco

Philips Pinnacle

RaySearch RayStation

Varian Eclipse

Other (please specify)

Question Title

* 4. Which treatment techniques are employed by your center when planning cranial SRS cases?

Conformal Arc

Conical Collimator

Dynamic Conformal Arc (DCA)

Intensity Modulated Radiation Therapy (IMRT)

Volumetric Modulated Arc Therapy (VMAT)

Other (please specify)

Question Title

* 5. What is the number of unique patients receiving cranial SRS treatments in the past year? Please specify the number of new patients versus re-treatments for these CPT codes: Neurosurgery 61781, 61782, 61796, 61797, 61798, 61799, 61800 and Radiation Oncology 77432, 77371, 77372, 77432.

Number of new patients

Number of re-treatments

Question Title

* 6. Indicate which personnel are available at your site:

Neurosurgeon

Nurse or Nurse Practitioner

Physicist

Radiation Oncologist

Research Coordinator

Additional resources not listed above

Question Title

* 7. Which assessment tools (scales) are routinely used at your site as part of the regular standard of care, either before or after SRS treatments?

Question Title

* 8. Indicate which imaging studies are routinely performed at your site on SRS patients.

Question Title

* 9. Are patients primarily seen for follow-up at your location or at affiliated institutions?

At my location

At affiliated institution(s)

Name of Affiliated Institution(s)

Question Title

* 10. What percentage of cranial SRS patients are seen for follow-up exams at your location/institution?

% at 1 month

% at 3 months

% at 6 months

% at 12 months

Other intervals

Question Title

* 11. If patients are not seen at your location, do you have access to follow-up records and imaging from follow-ups at other locations/institutions?

Yes

Comments

Question Title

* 12. Does your facility currently maintain a database of SRS patients and/or outcomes measures?

Yes

If Yes, please describe

Question Title

* 13. Successful registry participation includes the ability to collect additional data, sometimes beyond current practices, which may include the following. Please check the types of data to which you have, or can establish, access.

Data outside of medical records

Information about other health events

Outcome measures not routinely collected, including patient-reported outcomes, as part of follow-up visits

Resection data

Survival data

Other (please specify)

Question Title

* 14. Which challenges, if any, do you foresee for participation by your site?

Contracting

Financial (i.e. grant administration)

IT infrastructure

Personnel (i.e. Research Coordinator)

Regulatory (i.e. Institutional Review Board)

Other (please specify)

Question Title

* 15. Please indicate the type of contracting entity that would be entering into an agreement with the NPA and Brainlab.

Healthcare System

Hospital/Medical Center

Group Practice

Individual Physician

Other (please specify)

Question Title

* 16. Does your center currently participate in SRS quality certification programs, such as the Novalis program, or other certification or accreditation programs?

Yes, we are Novalis Certified

Novalis application is in process

No, we are not certified/accredited

Don't know

Other certification/accreditation application is in process

Please specify other certification/accreditation program(s)

Question Title

* 17. Is your center interested in SRS quality certification programs?

Yes. Please provide information about the Novalis Certified program.

Don't know

SRS Registry Interest Form

Please provide your contact information and site details below.

Question Title

* 1. Contact Information

Question Title

* 2. Which devices are used at your center for cranial SRS treatment?

Question Title

* 3. Which treatment planning systems are used by your center for planning cranial SRS cases?

Question Title

* 4. Which treatment techniques are employed by your center when planning cranial SRS cases?

Question Title

* 5. What is the number of unique patients receiving cranial SRS treatments in the past year? Please specify the number of new patients versus re-treatments for these CPT codes: Neurosurgery 61781, 61782, 61796, 61797, 61798, 61799, 61800 and Radiation Oncology 77432, 77371, 77372, 77432.

Question Title

* 6. Indicate which personnel are available at your site:

Question Title

* 7. Which assessment tools (scales) are routinely used at your site as part of the regular standard of care, either before or after SRS treatments?

Question Title

* 8. Indicate which imaging studies are routinely performed at your site on SRS patients.

Question Title

* 9. Are patients primarily seen for follow-up at your location or at affiliated institutions?

Question Title

* 10. What percentage of cranial SRS patients are seen for follow-up exams at your location/institution?

Question Title

* 11. If patients are not seen at your location, do you have access to follow-up records and imaging from follow-ups at other locations/institutions?

Question Title

* 12. Does your facility currently maintain a database of SRS patients and/or outcomes measures?

Question Title

* 13. Successful registry participation includes the ability to collect additional data, sometimes beyond current practices, which may include the following. Please check the types of data to which you have, or can establish, access.

Question Title

* 14. Which challenges, if any, do you foresee for participation by your site?

Question Title

* 15. Please indicate the type of contracting entity that would be entering into an agreement with the NPA and Brainlab.

Question Title

* 16. Does your center currently participate in SRS quality certification programs, such as the Novalis program, or other certification or accreditation programs?

Question Title

* 17. Is your center interested in SRS quality certification programs?

Question Title

* 18. What are some of your goals for registry participation?