Skip to content
SRS Registry Interest Form
Please provide your contact information and site details below.
1.
Contact Information
Name
Organization Name
Address
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
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)
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)
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)
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
6.
Indicate which personnel are available at your site:
Neurosurgeon
Nurse or Nurse Practitioner
Physicist
Radiation Oncologist
Research Coordinator
Additional resources not listed above
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?
8.
Indicate which imaging studies are routinely performed at your site on SRS patients.
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)
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
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
No
Comments
12.
Does your facility currently maintain a database of SRS patients and/or outcomes measures?
Yes
No
If Yes, please describe
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)
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)
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)
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)
17.
Is your center interested in SRS quality certification programs?
Yes. Please provide information about the Novalis Certified program.
No
Don't know
18.
What are some of your goals for registry participation?
Current Progress,
0 of 18 answered
