NUCLEAR MEDICINE SKILLS CHECKLIST
Name:
When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill.

The scale is as follows:
1. Not performed   2. Intermitten experience   3. Very experienced.
Certifications/Procedures
  1. NM Director   Yes No   Years/months
  2. NM Supervisor   Yes No   Years/months
  3. Nuclear Cardiology Tech   Yes No   Years/months
  4. Registered Nuclear Medicine Tech ARRT   Yes No   Years/months
  5. Registered Nuclear Medicine Tech NMTCB   Yes No   Years/months
  6. Registry Eligible Nuclear Medicine Tech   Yes No   Years/months
Equipment
  1. 3-D Reconstruction Packet   Yes No   Years/months
  2. ADAC Camera   Yes No   Years/months
  3. ADAC Computer   Yes No   Years/months
  4. Centiview   Yes No   Years/months
  5. Digital Computer   Yes No   Years/months
  6. Elscint Camera   Yes No   Years/months
  7. GE LFOV   Yes No   Years/months
  8. GE MAXI 400 Camera   Yes No   Years/months
  9. GE Star 1 Computer   Yes No   Years/months
  10. GE Star Cam Computer   Yes No   Years/months
  11. GE Star Cam Spect   Yes No   Years/months
  12. Genesis   Yes No   Years/months
  13. Genesis Computer   Yes No   Years/months
  14. Hepatic Hemangloma   Yes No   Years/months
  15. Hitachi   Yes No   Years/months
  16. MDS Camera(Medisept)   Yes No   Years/months
  17. MDS Computer(Medisept)   Yes No   Years/months
  18. Micro Dot Computer   Yes No   Years/months
  19. Ohio Nuclear   Yes No   Years/months
  20. Ohio Nuclear 410 Camera   Yes No   Years/months
  21. Omega 500   Yes No   Years/months
  22. Omega 500 Computer   Yes No   Years/months
  23. Philips(NM)   Yes No   Years/months
  24. PhoGamma IV   Yes No   Years/months
  25. Picker(NM)   Yes No   Years/months
  26. Picker Prism   Yes No   Years/months
  27. Siemens Computer   Yes No   Years/months
  28. Siemens Diacam   Yes No   Years/months
  29. Siemens Orbiter Camera   Yes No   Years/months
  30. Siemens Spect   Yes No   Years/months
  31. Sophy Computer   Yes No   Years/months
  32. Summit   Yes No   Years/months
  33. Technicare 438 Camera   Yes No   Years/months
  34. Technicare 560 Camera   Yes No   Years/months
  35. Technicare Omega 500 Camera   Yes No   Years/months
  36. Technicare Port 420   Yes No   Years/months
  37. Technicare Port 550   Yes No   Years/months
  38. Toshiba 6000   Yes No   Years/months
  39. ZLC   Yes No   Years/months
  40. Other   Yes No   Years/months
Procefures
  1. 1-123 Uptake   Yes No   Years/months
  2. 1-131 Therapy   Yes No   Years/months
  3. Aerosol Lung Scan   Yes No   Years/months
  4. Bone Scan   Yes No   Years/months
  5. Brachytherapy   Yes No   Years/months
  6. Brain Scan   Yes No   Years/months
  7. Gerebral Blood Flow   Yes No   Years/months
  8. Gallium Scan   Yes No   Years/months
  9. GI Bleeding Study   Yes No   Years/months
  10. HIDA Scan   Yes No   Years/months
  11. Hot Lab   Yes No   Years/months
  12. Indium 1-11 WBC   Yes No   Years/months
  13. Liver Scan   Yes No   Years/months
  14. Muga Scan   Yes No   Years/months
  15. NVG Rest   Yes No   Years/months
  16. NVG Stress   Yes No   Years/months
  17. Persantine Thallium   Yes No   Years/months
  18. PET Scanning   Yes No   Years/months
  19. Radio Pharmaceutical Prep   Yes No   Years/months
  20. Radionuclide Arteriogram   Yes No   Years/months
  21. Radionuclide Venogram   Yes No   Years/months
  22. Renagrams   Yes No   Years/months
  23. Renal Scan   Yes No   Years/months
  24. RIA(Radio Immuno Assay)   Yes No   Years/months
  25. Shillings   Yes No   Years/months
  26. Spect   Yes No   Years/months
  27. Spleen Scan   Yes No   Years/months
  28. Stress Holter Monitoring   Yes No   Years/months
  29. Testicular Studies   Yes No   Years/months
  30. Thallium Stress Test   Yes No   Years/months
  31. Three Phase Renal Scan   Yes No   Years/months
  32. Thyroid Scan   Yes No   Years/months
  33. Thyroid Therapy   Yes No   Years/months
  34. Thyroid Uptake   Yes No   Years/months
  35. VP Lung Scan   Yes No   Years/months
  36. Other   Yes No   Years/months
Settings
  1. Applications   Yes No   Years/months
  2. Clinic   Yes No   Years/months
  3. Doctors Office   Yes No   Years/months
  4. Hospital   Yes No   Years/months
  5. Management Experience(NM)   Yes No   Years/months
  6. Mobile Toute   Yes No   Years/months
  7. Nuclear Cardiology   Yes No   Years/months
  8. Teachings/Educational   Yes No   Years/months
  9. Other   Yes No   Years/months

Additional Certifications / Education
The information I have given is true and accurate to the best of my knowledge. Please sign and date below.
SIGNATURE: (Last 4 digits of your SSN)    Reenter your last 4 digits of your SSN:   DATE:

  
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