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)

ANGIO STUDIES

Abdominal Aorta(Required)
Chest / Arch(Required)
Circle of Willis(Required)
Upper & Lower Extremities(Required)
Carotids / Neck(Required)
Renal Arteries(Required)
Subclavian(Required)

VENOGRAM STUDIES

Carotids / Neck(Required)
Renal Arteries(Required)
Pelvis(Required)
Upper & Lower Extremities(Required)

MR STUDIES

Cardiac MRI(Required)
Head / Neck(Required)
Brain / Head With / Without Contrast(Required)
Face With / Without Contrast(Required)
Pituitary With / Without Contrast(Required)
Soft Tissue Neck With / Without Contrast(Required)
TMJ With / Without Contrast(Required)

ABDOMEN/PELVIS

Abdomen With / Without Contrast(Required)
Adrenals With / Without Contrast(Required)
Cholangiogram(Required)
Pelvis With / Without Contrast(Required)
Sacroiliac Joint With / Without Contrast(Required)
Renal With / Without Contrast(Required)

CHEST

Brachial Plexus(Required)
Breast With / Without Contrast(Required)
Chest With / Without Contrast(Required)
Myocardium With / Without Contrast(Required)
Sternum With / Without Contrast(Required)

UPPER EXTREMITIES

Scapula With / Without Contrast(Required)
Shoulder With / Without Contrast(Required)
Arthrogram Shoulder(Required)
Elbow / Wrist With / Without Contrast(Required)
Hand / Finger With / Without Contrast(Required)
Humerus With / Without Contrast(Required)

LOWER EXTERMITIES

Hip With / Without Contrast(Required)
Knee With / Without Contrast(Required)
Foot / Ankle With / Without Contrast(Required)
Femur / Tibia With / Without Contrast(Required)

PHASE ARRAY

Head(Required)
Neurovascular(Required)
Spine(Required)
Torso(Required)

SURFACE COILS

Extremity(Required)
Shoulder(Required)
TMJ(Required)

IMAGES

Echo Planar Imaging – EPI(Required)
Gradient Echo Imaging(Required)
Multiplanar Reconstruction / MRA(Required)
Spin Echo Images(Required)
T-1 Weighted(Required)
T-2 Weighted(Required)
Inversion Recovery(Required)
Fat Suppression(Required)
Fiesta(Required)

MRI IMAGING SYSTEMS

Diasonics(Required)
Elscint(Required)
Fonar(Required)
GE .5 Tesla(Required)
GE Baby Signa Mobile(Required)
GE Echospeed(Required)
GE Max Encore(Required)
GE Signa 5x(Required)
Hitachi(Required)
Hitachi Airis(Required)
Hitachi MRP – 7000(Required)
Lunar Artoscan M(Required)
Philips T5(Required)
Philips Gyroscan(Required)
Picker(Required)
Picker Edge Eclipse(Required)
Picker Merit(Required)
Picker Vista HPQ(Required)
Siemens(Required)
Siemens Impact Expert(Required)
Technicare(Required)
Toshiba(Required)
Toshiba Access(Required)
Toshiba MRT(Required)

PROFESSIONAL KNOWLEDGE AND SKILLS

National Patient Safety Goals(Required)
Computerized Charting(Required)
Venipuncture(Required)
Contrast Administration(Required)
Imaging a Patient With Conscious Sedation(Required)
Imaging a Patient Under Anesthesia(Required)
Patient Isolation / Infection Prevention(Required)
Certifications / Licensures / Regis(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)

WORK SETTING

Adult Acute Care(Required)
Adult Outpatient(Required)
Pediatric Acute Care(Required)
Pediatric Outpatient(Required)
Trauma(Required)
Outpatient Clinical / Free-Standing Clinic(Required)
Mobile(Required)
Supervisory / Management Experience(Required)

OTHER SKILLS