X-Ray Technologist

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Name*

First Last

Phone*

Email*

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

Middle Adults (39 - 64 years) *

Middle Adults (39 - 64 years) proficiency*

Middle Adults (39 - 64 years) frequency*

Older Adults (64+ years) *

Older Adults (64+ years) proficiency*

Older Adults (64+ years) frequency*

Elderly Adults (over 79+ years) *

Elderly Adults (over 79+ years) proficiency*

Elderly Adults (over 79+ years) frequency*

General Skills

Proficiency Rating

Frequency Rating

Standard Precautions *

Standard Precautions proficiency*

Standard Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Pediatric Respiratory / Cardiac Arrest *

Pediatric Respiratory / Cardiac Arrest proficiency*

Pediatric Respiratory / Cardiac Arrest frequency*

Adult Respiratory / Cardiac Arrest *

Adult Respiratory / Cardiac Arrest proficiency*

Adult Respiratory / Cardiac Arrest frequency*

Work Setting

Proficiency Rating

Frequency Rating

Adult Acute Care *

Adult Acute Care proficiency*

Adult Acute Care frequency*

Adult Outpatient *

Adult Outpatient proficiency*

Adult Outpatient frequency*

Pediatric Acute Care *

Pediatric Acute Care proficiency*

Pediatric Acute Care frequency*

Pediatric Outpatient *

Pediatric Outpatient proficiency*

Pediatric Outpatient frequency*

Bedside / Portable Procedures *

Bedside / Portable Procedures proficiency*

Bedside / Portable Procedures frequency*

ER / Trauma *

ER / Trauma proficiency*

ER / Trauma frequency*

OR *

OR proficiency*

OR frequency*

Chest and Thorax

Proficiency Rating

Frequency Rating

Chest Routine *

Chest Routine proficiency*

Chest Routine frequency*

Chest SP *

Chest SP proficiency*

Chest SP frequency*

Ribs *

Ribs proficiency*

Ribs frequency*

Chest Lateral Decubitus *

Chest Lateral Decubitus proficiency*

Chest Lateral Decubitus frequency*

Sternum *

Sternum proficiency*

Sternum frequency*

Upper Airway (Soft - Tissue Neck) *

Upper Airway (Soft - Tissue Neck) proficiency*

Upper Airway (Soft - Tissue Neck) frequency*

Upper Extremity

Proficiency Rating

Frequency Rating

Thumb or Finger *

Thumb or Finger proficiency*

Thumb or Finger frequency*

Hand *

Hand proficiency*

Hand frequency*

Wrist *

Wrist proficiency*

Wrist frequency*

Forearm *

Forearm proficiency*

Forearm frequency*

Elbow *

Elbow proficiency*

Elbow frequency*

Humerus *

Humerus proficiency*

Humerus frequency*

Shoulder *

Shoulder proficiency*

Shoulder frequency*

Trauma *

Trauma proficiency*

Trauma frequency*

Clavicle *

Clavicle proficiency*

Clavicle frequency*

Scapula *

Scapula proficiency*

Scapula frequency*

AC Joints *

AC Joints proficiency*

AC Joints frequency*

Lower Extremity

Proficiency Rating

Frequency Rating

Toes *

Toes proficiency*

Toes frequency*

Foot *

Foot proficiency*

Foot frequency*

Ankle *

Ankle proficiency*

Ankle frequency*

Knee *

Knee proficiency*

Knee frequency*

Tibia - Fibula *

Tibia - Fibula proficiency*

Tibia - Fibula frequency*

Femur *

Femur proficiency*

Femur frequency*

Trauma *

Trauma proficiency*

Trauma frequency*

Patella *

Patella proficiency*

Patella frequency*

Calcaneus *

Calcaneus proficiency*

Calcaneus frequency*

Head

Proficiency Rating

Frequency Rating

Skull *

Skull proficiency*

Skull frequency*

Paranasal Sinuses *

Paranasal Sinuses proficiency*

Paranasal Sinuses frequency*

Facial Bones *

Facial Bones proficiency*

Facial Bones frequency*

Orbits *

Orbits proficiency*

Orbits frequency*

Zygomatic Arches *

Zygomatic Arches proficiency*

Zygomatic Arches frequency*

Nasal Bones *

Nasal Bones proficiency*

Nasal Bones frequency*

Mandible *

Mandible proficiency*

Mandible frequency*

TMJ *

TMJ proficiency*

TMJ frequency*

Spine and Pelvis

Proficiency Rating

Frequency Rating

Cervical Spine *

Cervical Spine proficiency*

Cervical Spine frequency*

Thoracic Spine *

Thoracic Spine proficiency*

Thoracic Spine frequency*

Lumbar Spine *

Lumbar Spine proficiency*

Lumbar Spine frequency*

Sacrum and / or Coccyx *

Sacrum and / or Coccyx proficiency*

Sacrum and / or Coccyx frequency*

Cross - Table Lateral Spine *

Cross - Table Lateral Spine proficiency*

Cross - Table Lateral Spine frequency*

Pelvis *

Pelvis proficiency*

Pelvis frequency*

Hip *

Hip proficiency*

Hip frequency*

Cross - Table Lateral Hip *

Cross - Table Lateral Hip proficiency*

Cross - Table Lateral Hip frequency*

Scoliosis Series *

Scoliosis Series proficiency*

Scoliosis Series frequency*

Sacroiliac Joints *

Sacroiliac Joints proficiency*

Sacroiliac Joints frequency*

Abdomen

Proficiency Rating

Frequency Rating

Abdomen Supine (KUB) *

Abdomen Supine (KUB) proficiency*

Abdomen Supine (KUB) frequency*

Abdomen Upright *

Abdomen Upright proficiency*

Abdomen Upright frequency*

Abdomen Decubitus *

Abdomen Decubitus proficiency*

Abdomen Decubitus frequency*

Fluoroscopy Studies

Proficiency Rating

Frequency Rating

Upper GI Series, Single or Double Contrast *

Upper GI Series, Single or Double Contrast proficiency*

Upper GI Series, Single or Double Contrast frequency*

Upper GI Series, Single or Double Contrast *

Upper GI Series, Single or Double Contrast proficiency*

Upper GI Series, Single or Double Contrast frequency*

Small Bowel Series *

Small Bowel Series proficiency*

Small Bowel Series frequency*

Esophagus *

Esophagus proficiency*

Esophagus frequency*

Cystography / Cystourethrography *

Cystography / Cystourethrography proficiency*

Cystography / Cystourethrography frequency*

ERCP *

ERCP proficiency*

ERCP frequency*

Myelography *

Myelography proficiency*

Myelography frequency*

Arthrography *

Arthrography proficiency*

Arthrography frequency*

Hysterosalpingography *

Hysterosalpingography proficiency*

Hysterosalpingography frequency*

Mobile Radiographic Studies

Proficiency Rating

Frequency Rating

Chest *

Chest proficiency*

Chest frequency*

Abdomen *

Abdomen proficiency*

Abdomen frequency*

Orthopedic *

Orthopedic proficiency*

Orthopedic frequency*

Equipment

Proficiency Rating

Frequency Rating

GE *

GE proficiency*

GE frequency*

List Types:

Fuji *

Fuji proficiency*

Fuji frequency*

List Types:

Siemens *

Siemens proficiency*

Siemens frequency*

List Types:

Toshiba *

Toshiba proficiency*

Toshiba frequency*

List Types:

Hitachi *

Hitachi proficiency*

Hitachi frequency*

List Types:

Portables *

Portables proficiency*

Portables frequency*

List Types:

C-Arm *

C-Arm proficiency*

C-Arm frequency*

List Types:

Computerized Charting

Proficiency Rating

Frequency Rating

EMR

eClinicalworks *

eClinicalworks proficiency*

eClinicalworks frequency*

EPIC *

EPIC proficiency*

EPIC frequency*

McKesson *

McKesson proficiency*

McKesson frequency*

Care 360 *

Care 360 proficiency*

Care 360 frequency*

Allscripts *

Allscripts proficiency*

Allscripts frequency*

Cerner *

Cerner proficiency*

Cerner frequency*

GE *

GE proficiency*

GE frequency*

Optum Insight *

Optum Insight proficiency*

Optum Insight frequency*

NextGen *

NextGen proficiency*

NextGen frequency*

Greenway *

Greenway proficiency*

Greenway frequency*

PACS

Ambra Health *

Ambra Health proficiency*

Ambra Health frequency*

Sectra *

Sectra proficiency*

Sectra frequency*

Infinitt *

Infinitt proficiency*

Infinitt frequency*

IBM Merge *

Lithotripsy proficiency*

IBM Merge frequency*

McKesson *

McKesson proficiency*

McKesson frequency*

Philips *

Philips proficiency*

Philips frequency*

FujiFilm *

FujiFilm proficiency*

FujiFilm frequency*

Impax *

Impax proficiency*

Impax frequency*

Centricity *

Centricity proficiency*

Centricity frequency*

Carestream Vue *

Carestream Vue proficiency*

Carestream Vue frequency*

Clarity *

Clarity proficiency*

Clarity frequency*

eRad PACS *

eRad PACS proficiency*

eRad PACS frequency*

Syngo *

Syngo proficiency*

Syngo frequency*

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Date*

Skills/Competences

Proficiency

Frequency

X-RAY TECHNOLOGIST

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