Mammographer Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

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 *

Advanced directives	123
Vital Signs	123
Care of patients in restraints	123
Use of transfer/lifting devices	123
Care of patients in isolation	123
Knowledge of "Do Not Use Abbreviations"	123
Charge/Supervisor experience	123
Knowledge of current Joint Commission National Patient Safety Goals	123
Knowledge/familiarity with HCAHPS scores	123
IV Pumps: Alaris	123
IV Pumps: Alibaba	123
IV Pumps: Bard	123
IV Pumps: Baxter	123
IV Pumps: Braun	123
IV Pumps: Other	123

MAMMOGRAPHY:

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 *

Bilateral Mammogram	123
Density Settings	123
Digital Mammography	123
Implants	123
Irradiated Breasts	123
Male Breast Scan	123
Mammography Quality Standards Act	123
Needle Aspiration	123
Needle Localization	123
Optical Breast Screening	123
Post Partum Mastitis	123
Reduction Mammoplasty	123
Specimen Radiographs	123
Spot Compression View	123
Stereotactic Core Biopsy	123
Self Breast Exams	123

TYPES OF EQUIPMENT:

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 *

GE	123
Philips	123
Siemens	123
Toshiba	123
PACS System	123
RIS-Cerner	123

WORK SETTING:

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 *

Hospital Experience	123
Clinic Experience	123
Teaching/Educational Facility	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 to 30 days)	123
Infant (31 days to 12 months)	123
Toddler/Preschool (13 months to 5 years)	123
School Age Child/adolescent (6 years to 18 years)	123
Young Adults/Middle Adult (19 years to 64 years)	123
Older Adults/Elderly (65+ 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. *