Please rate your experience / frequency within the last year

0 = No Experience / Observed Only
1 = Limited Experience / Rarely Done (<6 times/year)
2 = May Need Some Review / Occasionally Done (1 – 2 times/month)
3 = Experienced / Frequently Done (daily or weekly)

MM slash DD slash YYYY

AGE OF CLIENTS:

Newborn/Neonate (birth to 30 days)(Required)
Infant (31 days to 12 months)(Required)
Toddler/Preschool (13 months to 5 years)(Required)
School Age Child/adolescent (6 years to 18 years)(Required)
Young Adults Middle Adult (19 years to 64 years)(Required)
Older Adults/Elderly (65+years)(Required)

HEAD AND NECK

Orbits(Required)
Facial Bones / Maxillofacial(Required)
Sinuses(Required)
Mastoids(Required)
Internal Auditory Canal(Required)
Temporal Bones(Required)
Posterior Fossa(Required)
Larynx(Required)
Neck Soft Tissue(Required)
Brain With Contrast(Required)
Brain Without Contrast(Required)
Circle of Willis(Required)

SPINE

Cervical Spine(Required)
Lumbar Spine(Required)
Sacral Spine(Required)
Trauma Spinal Scan(Required)
Post Myelogram Scan(Required)

CHEST

Heart(Required)
Lung(Required)
Mediastinum(Required)
Thoracic Aortic Dissection(Required)
Pulmonary Embolism(Required)
Vascular(Required)

ABDOMEN AND PELVIS

Abdominal Aortic Aneurysm(Required)
Adrenals(Required)
Appendix(Required)
Abdomen With Contrast(Required)
Abdomen Without Contrast(Required)
Oral Contrast Studies(Required)
Enema Contrast Studies(Required)
IV Contrast Studies(Required)
Gallbladder(Required)
Pancreas(Required)
Liver(Required)
Kidney(Required)
Renal Calculi(Required)
Spleen(Required)
Bladder(Required)
Hip(Required)
Pelvis(Required)

UPPER EXTREMITIES

Elbow(Required)
Wrist(Required)
Hand(Required)

LOWER EXTREMITIES

Knee(Required)
Ankle(Required)
Foot(Required)

OTHER

CTA's(Required)
Biopsy Procedures(Required)
CT Guided Thoracic Drainage(Required)
CT Guided Abdominal Drainage(Required)
CT Guided Abdominal Drainage(Required)
Pediatric Head CT(Required)
Pediatric Abdominal CT(Required)
ER / Trauma CT Scans(Required)
Radiation Therapy Planning(Required)
RF Ablations With CT(Required)

EQUIPMENT

Use of Contrast Dye(Required)
CT Dynamic and Serio Scans(Required)
CT Xenon Studies(Required)
3-D Imaging(Required)
3-D Reconstruction(Required)
3-D Surface Rendering(Required)
Gradient Echo Imaging(Required)
Surface Coils(Required)
Multiplanar Reconstruction(Required)
Radiation Badge(Required)
High Speed Advantage(Required)
Kodak Processor(Required)
Power Injectors: Single Head(Required)
Power Injectors: Dual Head(Required)
Angiomat Illumena Power Injector(Required)
CT 9000 ADV Power Injector(Required)
Optistat Power Injector(Required)
OptiVantage Power Injector(Required)
General Electric (GE)(Required)
8 Slice(Required)
16 Slice(Required)
32 Slice(Required)
64 Slice(Required)
Siemens(Required)
8 Slice(Required)
16 Slice(Required)
32 Slice(Required)
64 Slice(Required)
Phillips(Required)
Toshiba(Required)
Picker(Required)
HP(Required)

GENERAL SKILLS

Patients in Restraints(Required)
Lifting / Transfer Devices(Required)
Cardiac Arrest / CPR(Required)
Use of Rapid Response Teams(Required)
Universal Precautions(Required)
Working With Patient Under Conscious Sedation(Required)
Patient / Family Teaching of CT Procedures(Required)

NATIONAL PATIENT SAFETY GOALS

Accurate Patient Identification(Required)
Effective Communication(Required)
Infection Control(Required)
Universal Precautions(Required)
Patients in Isolation(Required)
Minimize Risk for Fall(Required)

OTHER SKILLS