ICPO Centers Network Application Form V2.0

  • ICPO Clinical Theranostics Center - Accreditation Application Form

  • Application Process

  • To apply for ICPO Clinical Theranostics Center status, please fill out the required information in this form.

    The ICPO Centers Team, namely Dr. Marwa Hakkam, Accreditation & Centers Project Director (regions: Middle East, Latam, Australia) and Karim Bouterfa, Academy & Centers Project Manager (regions: Europe, Asia, North America) will take care of the review in compliance with ICPO criteria. If necessary, additional details may be requested as needed.

  • How did your center first learn about ICPO Theranostics Center Accreditation?*

  • Section 1: General Information

  • Type of Institution*
  • Entity Type & Legal Status*
  • Is the entity in good standing with relevant regulatory authorities?*
  • Do you have a valid radiation license?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have a Radiation Safety Officer (RSO) or trained personnel available in compliance with local regulations?*

  • Person responsible for the present application

  • Section 2: Imaging & Regulatory Compliance

  • Equipment Availability

  • PET-CT:

  • Do you have a Gamma Camera?*
  • Is the Gamma Camera internationally credentialed?*
  • Do you have a PET-CT Scanner?*
  • Aditionally, do you have a collaboration with an imaging partner for PET-CT?*
  • If "Yes", how many collaborations do you have?*
  • Available PET-CT Imaging Isotopes at your Center:*
  • Are your PET-CTs internationally credentialed?*
  • Do you use your PET-CTs in oncology clinical trials?*

  • PET-MR:

  • Do you have a PET-MR Scanner?*
  • Available PET-MR Imaging Isotopes at your Center:*
  • Is the PET-MR internationally credentialed?*
  • Do you use your PET-MRs in oncology clinical trials?*

  • SPECT-CT:

  • Do you have a SPECT-CT?*
  • Aditionally, do you have a collaboration with an imaging partner for SPECT-CT?*
  • If "Yes", how many collaborations do you have?*
  • Available SPECT-CT Imaging Isotopes at your Center:*
  • Is the SPECT-CT internationally credentialed?*
  • Do you use yor SPECT-CTs in oncology clinical trials?*

  • Quality Assurance & Compliance

  • Do you have a quality assurance program?*
  • If "QUANUM by IAEA", when was it obtained?*
     - -
  • If "No", do you have a regular equipment maintenance schedule?*

  • Section 3: Patient Care & Safety

  • Patient Safety Protocols

  • Are patient education materials available, including radiation safety guidelines and expected post-treatment outcomes?*
  • Do you have a management plan for emergency or serious events during therapy administration?*
  • Do you have access to an emergency department for immediate support if needed during theranostic procedures?*
  • Do you adhere to national guidelines for patient release after diagnostic procedures?*

  • Patient Satisfaction Survey

  • Do you run a patient satifaction survey?*
  • If "Yes", when do you collect patient satisfaction data?

  • Section 4: Staff Qualifications & Training

  • Minimum Required Staff

  • At least one lead medical practitioner (MP) trained in theranostics*
  • At least one nuclear medicine (NM) practitioner trained in theranostics*
  • At least one nurse, preferably with theranostics training*

  • Qualified Treatment Providers

  • Certified physician(s) interpreting molecular imaging studies*
  • Theranostics-trained nuclear medicine physicist(s)*
  • Theranostics-trained nuclear medicine technologist(s) as part of the therapy team*
  • Theranostics-trained radiochemist(s) or pharmacist(s) as part of your team
  • Patient coordinator trained in theranostics as part of your team*

  • Training & Professional Development

  • Participation in Level 1 ICPO Academy for Theranostics program*
  • Participation in nationally or internationally accredited training programs or others*
  • Observed a minimum of 5 theranostics administrations*
  • Completion of at least 1 supervised treatment*
  • Completion of a minimum of 5 hours of (CME) annually (10 CME Credits)?*
  • Active participation in training workshops, webinars, or symposia (minimum half-day annually)*
  • Are you hosting or leading theranostic trainings or sessions?*

  • Section 5: Clinical & Treatment Data

  • Radiopharmaceutical Therapy (PRT) Administration

  • Does your center administer at least one Radiopharmaceutical Therapy (PRT)*

  • Annual Patient and Therapy Volumes

  • Provide the number of patients and therapy cycles per year:

  • Outpatients:

  • Inpatients:

  • Available Radiopharmaceutical Therapies at your Center:*

  • Section 6: Quality Assurance & Data Management

  • Radionuclide Safety and QA Systems

  • License to use radionuclides*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Quality management system (QM) for radionuclide therapies, including therapy SOPs*
  • Activity meter with CE certification and a dedicated QA program in place*
  • Radiation protection equipment, (e.g. contamination monitors)*
  • Waste management system for radionuclide therapies*

  • Data Management

  • Use of electronic medical records (EMR) with secure storage of key documents*

  • Regulatory Compliance & Risk Management

  • Liability insurance meeting local regulations*
  • Any adverse findings from medical or radiation authorities within the past 3 years*

  • Section 7: Radiopharmaceutical Storage & Handling

  • Storage Facilities & Compliance

  • Adequate storage facilities for radiopharmaceuticals*
  • Safety measures in place for safe radiopharmaceuticals handling and storage*
  • Facility compliant with local storage regulations*

  • Radiation Monitoring & Safety

  • Staff radiation exposure monitoring per safety regulations?*
  • Radiation safety program, including contamination monitoring and protective equipment*

  • Section 8: ICPO Center Link - Information Request

  • ICPO is launching Center Link, an interactive map connecting patients directly with ICPO Centers to streamline referrals and improve visibility. Each participating center will receive a dedicated ICPO email address in the following format:

    ICPO-Center-Link.[YourAbbreviation]@icpo.foundation


    To set this up, please provide the information below. This will ensure patient referrals are routed securely to your team, improving coordination and access across our global network.


    Required Information

  • Section 9: Center Profile for Commmunication

  • Photos and Logo (Upload each file in PDF, JPG, or PNG format)

    To help promote your center via official ICPO channels and online resources, please provide the following information.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Why do we need this?
    Your photos, logo, and description will help patients and partners better understand your services and will strengthen your center’s visibility in the ICPO Global Network.

  • Short Center Description
    Provide a clear overview (up to 150 words), covering:
    • Infrastructure and key facilities (e.g., therapy rooms, imaging, radiopharmacy)
    • Treatments and services offered
    • Team size and roles (physicians, technologists, nurses)
    • Community or region served
    This description will appear in ICPO materials, on the website, and in outreach. Please keep it factual and up to date.

  • 0/150
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Section 10: Submission Confirmation

  • Date
     - -
  • Should be Empty: