ULTRASOUND 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.
Cardiology
  1. 2D and M-mode   1 2 3
  2. Color and Doppler (PW & CW)   1 2 3
  3. Pedof transducers   1 2 3
  4. Stress Testing   1 2 3
  5. TEE   1 2 3
  6. Portable Studies   1 2 3
  7. Fetal Heart   1 2 3
  8. Exercise Pharmacological   1 2 3
  9. Other Special Procedures:   1 2 3
Female Pelvis
  1. Uterus   1 2 3
  2. Ovaries   1 2 3
  3. Adnexa   1 2 3
  4. Vaginal   1 2 3
  5. Color/ or Doppler of above   1 2 3
  6. Other Special Procedures:   1 2 3
General Ultrasound
  1. Appendix   1 2 3
  2. Liver, Pancreas   1 2 3
  3. Gallblader, CBD   1 2 3
  4. Eye   1 2 3
  5. Kidneys, Spleen, Adrenals   1 2 3
  6. Paracentesis   1 2 3
  7. Thorocentesis   1 2 3
  8. Color /or Doppler of the areas listed above   1 2 3
  9. Intra Operative   1 2 3
  10. Other Special Procedures:   1 2 3
Male Pelvis
  1. Prostate (transabdominal)   1 2 3
  2. Prostat+e (transrectal)   1 2 3
  3. Bladder   1 2 3
  4. Color / or Doppler of above   1 2 3
  5. Other Special Procedures:   1 2 3
OB/GYN
  1. Level 1   1 2 3
  2. BPD, HC, AC, Fl   1 2 3
  3. Stomach, Heart, Kidneys   1 2 3
  4. Diaphragm Bladder   1 2 3
  5. Cerebellum, Ventricles   1 2 3
  6. Atria, Nuchal Fold   1 2 3
  7. Level II   1 2 3
  8. Fingers, Toes   1 2 3
  9. Bone Lengths   1 2 3
  10. Nose and Lips   1 2 3
  11. Inter & Intraorbital Measurements   1 2 3
  12. Atria and Cisterna Magnum   1 2 3
  13. Amniocentesis   1 2 3
  14. AFI and BPP   1 2 3
  15. Other Special Procedures:   1 2 3
Settings
  1. Applications   1 2 3
  2. Clinic   1 2 3
  3. Doctors office   1 2 3
  4. Hospital   1 2 3
  5. Management Experience   1 2 3
  6. Mobile Route   1 2 3
  7. Other   1 2 3
Small Parts
  1. Thyroids   1 2 3
  2. Breasts   1 2 3
  3. Testicles   1 2 3
  4. Superficial Masses   1 2 3
  5. Biopsies of these areas   1 2 3
  6. Color/ or Doppler of the above   1 2 3
  7. Other Special Procedures:   1 2 3
Vascular Technology
  1. Upper Extremity Venous   1 2 3
  2. Upper Extremity Arterials   1 2 3
  3. Lower Extremity Venous   1 2 3
  4. Lower Extremity Arterials   1 2 3
  5. Carotids   1 2 3
  6. Abdominal Aorta, IVC   1 2 3
  7. SMA, Celiac, Renals   1 2 3
  8. Hepatic, Splenic   1 2 3
  9. Resistive Index   1 2 3
  10. Pulsatility Index   1 2 3
  11. Color/ or Doppler   1 2 3
  12. Area for % Stenosis   1 2 3
  13. Diameter for % Stenosis   1 2 3
  14. PW and/or CW for % Stenosis   1 2 3
  15. PVR (arms and legs)   1 2 3
  16. IPG (arms and legs)   1 2 3
  17. Plethysmography for finger, toes, TOS   1 2 3
  18. Penile Doppler   1 2 3
  19. TCD   1 2 3
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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