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?*

From attending a congressRecommended by another ICPO network centerOnline search / ICPO websiteOther
By submitting this form, you acknowledge that the provided data will be used for future assessment and auditing processes related to accreditation by ICPO and accreditation by mutually recognized bodies.*

I hereby declare that the information provided might be used in future assessment and auditing.
Section 1: General Information
Institution Name*
Institution Website*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of Institution*

Public HospitalPrivate Hospital / Medical CenterUniversity / Academy InstitutionOther (please specify)
Entity Type & Legal Status*

Non-Profit OrganizationCompanyOther (please specify)
Is the entity in good standing with relevant regulatory authorities?*

YesNo
If "No", please specify:*
Do you have a valid radiation license?*

YesNo
If Yes, please attach a copy of your valid radiation license:*

Cancelof
Do you have a Radiation Safety Officer (RSO) or trained personnel available in compliance with local regulations?*

YesNo
Person responsible for the present application
Name*

First NameLast Name
Role*
E-Mail*
example@example.com
Confirmation*

I hereby confirm that the information provided is true and accurate and has been reviewed and approved by the Theranostics Center Head.
Section 2: Imaging & Regulatory Compliance
Equipment Availability
How many patients per year had oncological imaging procedures (PET-CT, PET-MR, SPECT-CT) at your center?*
PET-CT:
Do you have a Gamma Camera?*

YesNo
If "Yes", how many?*
Is the Gamma Camera internationally credentialed?*

YesNo
If "Yes", please specify the credentialing body?*
Do you have a PET-CT Scanner?*

YesNo
If "Yes", how many?*
Aditionally, do you have a collaboration with an imaging partner for PET-CT?*

YesNo
If "Yes", how many collaborations do you have?*

0122+
How many oncology PET-CT imaging procedures do you perform per year?*
Available PET-CT Imaging Isotopes at your Center:*

F-18Zr-89Ga-68Cu-64I-124Sc-44Other
F-18: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
Zr-89: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
Ga-68: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
Cu-64: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
I-124: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
Sc-44: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
Other isotopes: Please indicate as a percentage how many of your PET-CT imaging procedures you perform:*
What percentage of oncology PET-CT imaging procedures are done for Diagnosis/Screening? *
What percentage of oncology PET-CT imaging procedures are done for Staging/Follow-Up? *
Are your PET-CTs internationally credentialed?*

Yes, all PET-CTs are credentialedYes, 1 PET-CT isNone
If "Yes", please specify the credentialing body?*
Do you use your PET-CTs in oncology clinical trials?*

YesNo
If "yes", please specify
PET-MR:
Do you have a PET-MR Scanner?*

YesNo
If "Yes", how many?*
In which case PET-MR is preferred to PET-CT? *
How many oncology PET-MR imaging procedures do you perform per year?*
Available PET-MR Imaging Isotopes at your Center:*

F-18Zr-89Ga-68Cu-64C-11Sc-44Other
F-18: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
Zr-89: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
Ga-68: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
Cu-64: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
C-11: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
Sc-44: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
Other isotopes: Please indicate as a percentage how many of your PET-MR imaging procedures you perform:*
What is the percentage of oncology PET-MR imaging procedures done for Diagnosis/Screening? *
What is the percentage of oncology PET-MR imaging procedures done for Staging/Follow-Up? *
Is the PET-MR internationally credentialed?*

YesNo
If "Yes", please specify the credentialing body?*
Do you use your PET-MRs in oncology clinical trials?*

YesNo
If "yes", please specify
SPECT-CT:
Do you have a SPECT-CT?*

YesNo
If "Yes", how many?*
Aditionally, do you have a collaboration with an imaging partner for SPECT-CT?*

YesNo
If "Yes", how many collaborations do you have?*

0122+
How many oncology SPECT-CT imaging procedures do you perform per year?*
Available SPECT-CT Imaging Isotopes at your Center:*

Tc-99mIn-111I-131Lu-177Ga-67Other
TC-99m: Please indicate as a percentage how many of your SPECT-CT imaging procedures you perform:*
In-111: Please indicate as a percentage how many of your SPECT-CT imaging procedures you perform:*
I-131: Please indicate as a percentage how many of your SPECT-CT imaging procedures you perform:*
Lu-177: Please indicate as a percentage how many of your SPECT-CT imaging procedures you perform:*
Ga-67: Please indicate as a percentage how many of your SPECT-CT imaging procedures you perform:*
Other Isotopes: Please indicate as a percentage how many of your SPECT-CT imaging procedures you perform:*
What is the percentage of oncology SPECT-CT imaging procedures done for Diagnosis/Screening? *
What is the percentage of oncology SPECT-CT imaging procedures done for Staging/Follow-Up? *
Is the SPECT-CT internationally credentialed?*

YesNo
If "Yes", please specify the credentialing body?*
Do you use yor SPECT-CTs in oncology clinical trials?*

YesNo
If "yes", please specify
Quality Assurance & Compliance
Do you have a quality assurance program?*

Yes, QUANUM by IAEAYes, by National BodyNo
If "QUANUM by IAEA", when was it obtained?*

MonthDayYear
Date
If "National Body", specify the accreditation body*
If "No", do you have a regular equipment maintenance schedule?*

YesNo
Section 3: Patient Care & Safety
Patient Safety Protocols
Are patient education materials available, including radiation safety guidelines and expected post-treatment outcomes?*

YesNo
Do you have a management plan for emergency or serious events during therapy administration?*

YesNo
Do you have access to an emergency department for immediate support if needed during theranostic procedures?*

YesNo
Do you adhere to national guidelines for patient release after diagnostic procedures?*

YesNo
If "No", please specify*
Patient Satisfaction Survey
Do you run a patient satifaction survey?*

YesNo
If "Yes", when do you collect patient satisfaction data?

before treatmentduring treatmentafter treatment
Section 4: Staff Qualifications & Training
Minimum Required Staff
At least one lead medical practitioner (MP) trained in theranostics*

YesNo
If Yes, how many medical practitioners (MP) are trained in theranostics?*
At least one nuclear medicine (NM) practitioner trained in theranostics*

YesNo
If Yes, how many nuclear medicine (NM) practitioners are trained in theranostics?*
At least one nurse, preferably with theranostics training*

YesNo
If Yes, how many nurses do you have?*
Qualified Treatment Providers
Certified physician(s) interpreting molecular imaging studies*

YesNo
If Yes, how many certified physician(s) for interpreting molecular imaging studies do you have?*
Theranostics-trained nuclear medicine physicist(s)*

YesNo
If Yes, how many theranostics-trained nuclear medicine physicist(s) do you have?*
Theranostics-trained nuclear medicine technologist(s) as part of the therapy team*

YesNo
If Yes, how many theranostics-trained nuclear medicine technologists do you have?*
Theranostics-trained radiochemist(s) or pharmacist(s) as part of your team

YesNo
If Yes, how many theranostics-trained radiochemist(s) or pharmacist(s) do you have?*
Patient coordinator trained in theranostics as part of your team*

YesNo
If "Yes", how many?*
Total number of staff in your departement*
Training & Professional Development
Participation in Level 1 ICPO Academy for Theranostics program*

YesNo
If "Yes", how many staff members have met this requirement?*
Participation in nationally or internationally accredited training programs or others*

YesNo
If "Yes", please specify program*
If "Yes", how many staff members have met this requirement?*
Observed a minimum of 5 theranostics administrations*

YesNo
If "Yes", how many staff members have met this requirement?
Completion of at least 1 supervised treatment*

YesNo
If "Yes", how many staff members have met this requirement?
Completion of a minimum of 5 hours of (CME) annually (10 CME Credits)?*

YesNo
If "Yes", how many staff members have met this requirement?*
Active participation in training workshops, webinars, or symposia (minimum half-day annually)*

YesNo
If Yes, please specify the type of event(s), topics covered, or titles of workshops/webinars:
If "Yes", how many staff members have met this requirement?*
Are you hosting or leading theranostic trainings or sessions?*

YesNo
If "Yes", please describe the form of trainings/sessions
Section 5: Clinical & Treatment Data
Radiopharmaceutical Therapy (PRT) Administration
Does your center administer at least one Radiopharmaceutical Therapy (PRT)*

YesNo
Annual Patient and Therapy Volumes
Provide the number of patients and therapy cycles per year:
Outpatients:
Number of patients/year:*
Number of therapy cycles/year:*
Inpatients:
Number of patients/year:*
Number of therapy cycles/year:*
Available Radiopharmaceutical Therapies at your Center:*

I-131Lu-177Tb-161Cu-67Ac-225Pb-212Sc-47Other
I-131: Please indicate as a percentage how many of your therapies procedures you perform:*
Lu-177: Please indicate as a percentage how many of your therapies procedures you perform:*
Tb-161: Please indicate as a percentage how many of your therapies procedures you perform:*
Cu-67: Please indicate as a percentage how many of your therapies procedures you perform:*
Ac-225: Please indicate as a percentage how many of your therapies procedures you perform:*
Pb-212:: Please indicate as a percentage how many of your therapies procedures you perform:*
Sc-47: Please indicate as a percentage how many of your therapies procedures you perform:*
Other isotopes: Please indicate as a percentage how many of your therapies procedures you perform:*
Section 6: Quality Assurance & Data Management
Radionuclide Safety and QA Systems
License to use radionuclides*

YesNo
If Yes, please upload you license to use radionuclides*

Cancelof
Quality management system (QM) for radionuclide therapies, including therapy SOPs*

YesNo
Activity meter with CE certification and a dedicated QA program in place*

YesNo
Radiation protection equipment, (e.g. contamination monitors)*

YesNo
Waste management system for radionuclide therapies*

YesNo
Data Management
Use of electronic medical records (EMR) with secure storage of key documents*

YesNo
Regulatory Compliance & Risk Management
Liability insurance meeting local regulations*

YesNo
Any adverse findings from medical or radiation authorities within the past 3 years*

YesNo
Section 7: Radiopharmaceutical Storage & Handling
Storage Facilities & Compliance
Adequate storage facilities for radiopharmaceuticals*

YesNo
If "No", please specify*
Safety measures in place for safe radiopharmaceuticals handling and storage*

YesNo
If "No", please specify*
Facility compliant with local storage regulations*

YesNo
If "No", please specify*
Radiation Monitoring & Safety
Staff radiation exposure monitoring per safety regulations?*

YesNo
If "No", please specify*
Radiation safety program, including contamination monitoring and protective equipment*

YesNo
If "No", please specify*
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
Center Abbreviation (max. 12 characters)*
Head of Center*

First NameLast Name
Head of Center Email*
example@example.com
Patient Coordinator*

First NameLast Name
Patient Coordinator Email*
example@example.com
Therapy Nurse

First NameLast Name
Therapy Nurse Email
example@example.com
Other Treating Physician

First NameLast Name
Other Treating Physician Email
example@example.com
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.
Photo of Head of Center*

Cancelof
Photo of Center (preferred entrance area)*

Cancelof
Official Center Logo*

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.
Short Center Description*

0/150
Additional Comments (Optional):
Upload Supporting Documents (if any):

Cancelof
Section 10: Submission Confirmation
Correctness / Approval*

I confirm that the information provided is true and accurate to the best of my knowledge and has been approved by the Head of Theranostics Center
Future Accreditation*

I acknowledge that the provided data may be used for future assessment and auditing processes related to ICPO accreditation and to accreditation by mutually recognized accreditation bodies
Cooperation*

I agree to cooperate with the ICPO Foundation to establish my institution as an ICPO collaborating centre, supporting the development and promotion of the ICPO Academy (including e-learning, certification, and practical training), participating in ICPO Community activities, contributing to standards development and center design, and collaborating on research, clinical trials, and other initiatives to expand patient access, promote precision oncology, and foster international best practices *.
Data Privacy*

By completing this ICPO accreditation form, you acknowledgeand agree that the ICPO Foundation may collect, process, and use the submitted data for activities related to quality assurance, certification, statistical evaluation,and potential research in the field of theranostics. The data may be shared internally, and with formal partners involved in these activities. Participating sites may be selected for audit to validate the accuracy and completeness of submitted data, in accordance with applicable legal, regulatory, and scientific standards. In such cases, the execution of a non-disclosure agreement (NDA) and a formal audit agreement will be required prior to initiation. By completing and submitting the enrolment form, centers expressly acknowledge ICPOs authority to conduct such audits and affirm their obligation to fully cooperate with the audit process as outlined in the governing agreements
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ICPO Clinical Theranostics Center - Accreditation Application Form

Application Process

Section 1: General Information

Section 2: Imaging & Regulatory Compliance

Equipment Availability

Quality Assurance & Compliance

Section 3: Patient Care & Safety

Patient Safety Protocols

Patient Satisfaction Survey

Section 4: Staff Qualifications & Training

Minimum Required Staff

Qualified Treatment Providers

Training & Professional Development

Section 5: Clinical & Treatment Data

Radiopharmaceutical Therapy (PRT) Administration

Annual Patient and Therapy Volumes

Section 6: Quality Assurance & Data Management

Radionuclide Safety and QA Systems

Data Management

Regulatory Compliance & Risk Management

Section 7: Radiopharmaceutical Storage & Handling

Storage Facilities & Compliance

Radiation Monitoring & Safety

Section 8: ICPO Center Link - Information Request

Section 9: Center Profile for Commmunication

Section 10: Submission Confirmation