Medical Physicist Skills Checklist

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Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

HIPAA Regulations	123
National Patient Safety Goals	123
Awareness of HCAHPS scores	123
Electronic Medical Record	123
Accurate Patient Identification	123
Demonstrates knowledge of anatomy	123
Proper body mechanics	123
Technique to preserve respect and dignity for patients	123
Introduction of self prior to providing care	123
Crash Carts	123
Defibrillator	123

CLINICAL SKILLS IN RADIOTHERAPY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Clinical environment	123
Clinical conduct	123
Chart checking	123
Verify and record systems	123
Radiation safety	123
Simulation	123

QUALITY ASSURANCE IN RADIATION ONCOLOGY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Linear accelerator	123
Acceptance testing and commissioning	123
Measurement equipment	123
CT simulator	123
Portal imaging and kV X-Ray imaging	123
Cone-Beam CT	123
PET-CT	123
HDR	123
Software Systems	123
Prevention of technology-related errors	123

TREATMENT PLANNING:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Prerequisites for treatment	123
Mark and start cases	123
3D-conformal	123
IMRT	123
Protocols	123
Secondary monitor unit (MU) checks	123
Block cutting	123
Diodes/TLD	123
Beam data collection, modeling, commissioning	123

SPECIALTY PROCEDURES:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Radiosurgery	123
LDR Brachytherapy	123
HDR Brachytherapy	123
TBI electrons and photons	123
IGRT methods	123
Rotational therapy	123
Proton therapy	123

HEALTH PHYSICS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Radiation Safety	123
Instruments for health physics measurements	123
Shielding calculations	123
Isotope procedures	123

INFECTION CONTROL:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hand hygiene	123
Precautions associated with PPE (transmission, contact, airborne, droplet)	123
Universal Precautions	123
Negative-pressure room	123
Prevention and protocols for HAIs (CAUTI, CLABSI, VAP)	123
Prevention and protocols for MRSA, C.DIFF, Sepsis, etc.	123

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Acute care hospital	123
Outpatient clinic	123
Long term care	123
Rehabilitation center	123
Home health/private duty	123
Hospice	123

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn / neonate (birth-30 days)	123
Infant (31 days-1 year)	123
Toddler (ages 2-3 years)	123
Preschool (ages 4-5 years)	123
School age (ages 6-12 years)	123
Adolescent (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adult (ages 40-64 years)	123
Older adult (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *