Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
  • AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Hospital Experience
    Clinic Experience
    Teaching/Educational Facility
    Vital Signs
    Care of patients in restraints
    Use of transfer/lifting devices
    IV Injection
    Positioning Patient
    Computerized Charting
    Obtaining Consent
    Dose Calibrator constancy check
    Survey Meter Operational check
    Daily Wipe Testing
    Hot Lab management generators
    Hot Lab Dose calibration
    Radiation level survey
    Hand/Clothing monitoring
    Proper use of syringe shield/gloves/lab coat
    Waste disposal
    Radioactive Spill procedure/response
    NRC Regulatory Guide
    Instructions regarding prenatal radiation exposure
    Knowledge of "Do Not Use Abbreviations"
    Experience as charge nurse/supervisor?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    IV Pumps
    Other IV Pumps:
    HEAD AND NECK
    Brain
    Carotid Artery
    Shunt Study
    Cisternography
    Gated SPECT ( post infarct)
    Parathyroid
    Hyperthyroid Treatment
    Thyroid Ablation
    Uptake Scan
    Cancer Survey
    SKELETAL/BONE
    Three Phase
    Whole Body
    Limited
    Bone Marrow Scan
    CARDIAC
    Myocardial Perfusion Imaging
    Stress Test/Thallium SPECI
    Infarction
    Dual Isotopes
    CCK Ejection Fraction
    MUGA Scan
    LUNG AND CHEST
    DTPA Aerosol
    Perfusion
    VQ Ventilation/Perfusion Scan
    ABDOMEN, GI AND GU
    GI Bleed
    Gastric Emptying
    Renal Flow
    With Lasix
    Flow/Function
    Three Phase
    Voiding Cystogram
    Captopril
    Liver/Spleen Study
    Liver Spect with Flow
    Gallbladder
    Meckel's Diverticulum
    HIDA and CCK-HIDA Scan
    Adrenal Scan
    Testicular
    ENDOCRINE/LYMPHATIC/TUMORS
    Lymphoscintigraphy
    Lymphatic Scan - Melanoma
    Injection-Lymphatic
    Gallium Scan
    PET Scan
    Indium 111 WBC Scan Whole Body
    Indium 111 WBC Scan Limited
    Abscess Localizations Individual Sites
    OTHER PROCEDURES
    Brachytherapy
    Planar Procedures
    SPECT Procedures
    Radionuclide Arteriogram/Venogram
    Schilling's Test
    Stress Holter Monitoring
    Gated NVG Stress/Rest
    ALARA ( As Low As Reasonably Achievable)
    EQUIPMENT USED
    Siemens
    GE
    Hitachi
    Phillips
    Other:
    Other:
    Other: