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Patient Census Forms: Radiation Oncology (Revised 12-12-19)

Revision History

When your survey date is confirmed, you will receive an e-mail asking you to submit cases of definitively treated patients who have recently completed treatment at your facility and have had at least one follow-up visit. Please submit your cases no later than 30 days prior to the survey date. Completion of census forms is to be directed by your radiation oncologist. Cases should include:

  • Breast

  • Prostate

  • Head and Neck

  • Lung

  • “Generic” cases (seminoma, esophagus, cervix, colo-rectal, etc.)

Submit five cases of each disease site for your main site and only 2-3 cases from each disease site for each of your satellite sites. In addition, cases selected should include all treatment modalities offered at your facilities, (e.g. IMRT, prostate seed implant, stereotactic radiosurgery). If you do not have five cases from a given disease site, you may submit additional generic cases. A minimum of two cases per physician will need to be reviewed. We will not review cases from any physician no longer in the practice.

We will select 10 cases from this list for review during the on-site survey. For multi-site surveys, 10 cases will be reviewed at the main site and at least 3-4 at each satellite site. For all cases, patient records including simulation information, DRRs, port films (hard copies if appropriate), and CT planning documentation must be available for the surveyor(s). If your facility has electronic images and/or medical records, you will need to provide electronic access to this information. If your practice has undergone a recent conversion to paperless medical records and cases we are reviewing were in the transition, please retrieve paper charts from offsite storage if any of them contain items not available in the EMR.

Use a unique patient identifier (ID number) that is not associated with the patient’s medical record number (MRN). Do not include patients’ names, social security numbers, or dates of birth. Your unique number will be the only number tied to the MRN during the time of the survey. You will need to provide the list of unique ID numbers with the corresponding MRNs to the surveyors. A template for your facility’s tracking purposes (NOT for submission to the ACR) is provided in the ACR’s Radiation Oncology Practice Accreditation Toolkit.

List the cases using a numbering system of your choice. For example, if Mr. John Doe is a patient with prostate cancer, and has the MRN of 1234567, you can assign that case with a random number (i.e. 0000-99, 9999, 001, 1). To ensure that all physicians in the practice are reviewed, physician initials must be included with random ID numbers.

Please indicate the following treatment codes next to relevant patient IDs if applicable:

Treatment Codes


Seed Implant





















The ROPA online submission process is illustrated below by disease site. Please note that the ACR does not require an electronic upload of patient charts and/or images. These will be reviewed onsite by our surveyors during the case review. Since data collection is performed on-site using a web-based process, please review the ACR’s Checklist for Site Survey in our article on Site Surveys in Radiation Oncology



Head and Neck



Changing Your Submitted Application 

The login user can add, edit, and delete cases before the ACR approves them for review. In your ROPA account, go to Data Collection and click the Census Sheets tab on the left, followed by the Next button on Page 1. Click the Delete link for the case(s) you wish to remove, the Add New Patient link for the case(s) you wish to add, and the Edit link for the case(s) you wish to change.

Once cases have been approved, you must notify the ACR of a case change request. Please review the requirements above, as some modalities have required cases for submission which may not be changed. Case change requests must come from an e-mail address listed on your accreditation account prior to the onsite survey. Please send an e-mail to with the following information:

  • FML ID number

  • Please remove (state case to drop/remove)

  • Please add (state case to add or change)

Revision History for this Article



Description of Revision(s)



Article created; FAQs incorporated; No criteria changes

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