Information
Client/Site
Main contact
Phone
Clinical contact
Phone
Prepared by
ASM
Sales
First contact
Backgrounds
Number of vaults in center
Total patients for center
Patients treated per day in vault
Percent IMRT for vault
R&V
Version
TPS
Version
As built provided while on site
Digital or hard copy
4DITC
Version
Linac model
Linac serial number
Linac energies
Linac software version
Linac manufacture date
MLC model
Couch model
Couch serial number
Couch Baseframe
Portal imaging
Model
Accessories type
Measurements
Elevation diagram
Distance from floor to isocenter (A)
Distance from isocenter to false ceiling (B)
If applicable, @IR camera (C)
Distance from false ceiling to concrete (D)
If applicable, @IR camera (E)
Plan diagram
Distance between lateral laser walls (A)
Distance from back wall to front wall (B)
If applicable, service area (F)
Distance from back wall from iso (C)
Length of maze (D)
Width of maze (E)
Maze wall width
Width of opening clearance
Height of opening clearance
Vault Characteristics
Existing flooring
Existing wall coverings
Any new items for quote (i.e. Cabinets)
Does the treatment room support ET generator and cabinet?
Are flat panel locations free and clear of obstructions?
Position 1?
Position 2?
Is the Ceiling arm location free and clear of obstructions?
IR camera?
Are there pre-existing open conduits accessing the treatment room?
Is there space to run conduits between the ET cabinets and the in room distribution box?
What is the capacity of the HVAC system?
Does the console area support additional ExacTrac (ETX) components?
Is there access behind the gantry stand of the LINAC?
Is there existing power available for the ETX generator?
Voltage that is available?
Is there existing power available for the ETX computer cabinet?
What is the length from the loading/unloading area to the treatment room entrance?
What is the length from the electrical closet to the treatment room entrance?
Is the loading area on the same level as the treatment room?
Is there adequate space in the loading/unloading area for Brainlab and construction?
Is the parking on the premises available?
Can the construction crew easily access the building?
Is there STORAGE space available for the ETX pre-installation and installation shipments?
Comments / Pictures
Comments
