Nuclear Medicine Technologist Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

PROCEDURES
Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Arteriogram/Radionuclide	1234
Abscess Localization Whole Body	1234
Abscess Localization Individual Sites	1234
CCK/Ejection Fraction	1234
Cisternogram	1234
CSF Leak Localization	1234
Gallium Scan	1234
Gastric Emptying	1234
GI Bleed	1234
HIDA Scan	1234
Indium 111 WBC Scan Whole Body	1234
Indium 111 WBC Scan Limited	1234
Injection-Lymphatic	1234
Lymphatic Scan-Melanoma	1234
Meckels Scan	1234
Morphine Augmentation	1234
MUGA Scan	1234
Radiopharmaceutical Prep	1234
Radionuclide Arteriogram	1234
Renagram	1234
Parathyroid	1234
Salivary Glands	1234
Ventricular Shunt	1234
Zevalin Treatment	1234
Hyperthyroid Treatment	1234
I 131 Therapy Thyroid Ablation	1234
Therapy Pain	1234

BONE SCAN

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Whole Body	1234
3 Phase	1234
Limited	1234

BRAIN SCAN

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Cerebral Blood Flow

1234

LIVER/SPLEEN SCAN

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Liver/Spleen Scan	1234
Liver Scan-Hemangioma	1234
Liver Imaging	1234
Liver Flow	1234

LUNG SCAN

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

DTPA Aerosol	1234
Perfusion	1234
Ventilation/Perfusion	1234

RENAL FLOW

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

With Lasix	1234
Flow/Function	1234
Three Phase	1234
Captopril	1234

SHUNT

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Abdominal	1234
Ventricular	1234

THYROID STUDIES

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Cancer Survey	1234
Uptake Scan	1234
I 123 Scan	1234

TUMOR LOCALIZATION

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Whole Body	1234
Limited	1234

NM SPECT

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Bone	1234
Brain	1234
Liver	1234
Liver Spect w/Flow	1234
Renal	1234

MYOCARDIAL

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Infarction	1234
Exercise/Rest-Single	1234
Exercise/Rest-Multiple	1234
Pharmacological Stress	1234
Thallium/Persantine	1234

PROFESSIONAL KNOWLEDGE AND SKILLS

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Quality Control Equipment	1234
Daily Surveys/Wipe Testing	1234
Hot Lab Management Dose Calibrators	1234
Hot Lab Management Generators	1234
Computerized Charting	1234
National Patient Safety Goals	1234
Universal Protocol Procedures/Core Measures	1234
Isolation Precautions	1234
Infection Prevention	1234
Age Specific/Population-Based Care	1234
Fall Risk Assessment/Prevention	1234

AGE SPECIFIC

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Under 12 Years Old	1234
Adolescents (12 to 18 years)	1234
Young Adults (18 to 39 years)	1234
Middle Adults (40 to 64 years)	1234
Older Adults (65 years & up)	1234

Attestation

ATTESTATION: *

I certify that the information provided 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. *