MRI 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*

Angio Studies

Proficiency Rating

Frequency Rating

Abdominal Aorta *

Abdominal Aorta proficiency*

Abdominal Aorta frequency*

Chest/Arch *

Chest/Arch proficiency*

Chest/Arch frequency*

Circle of Willis *

Circle of Willis proficiency*

Circle of Willis frequency*

Upper & Lower Extremities *

Upper & Lower Extremities proficiency*

Upper & Lower Extremities frequency*

Carotids/Neck *

Carotids/Neck proficiency*

Carotids/Neck frequency*

Renal Arteries *

Renal Arteries proficiency*

Renal Arteries frequency*

Venogram Studies

Proficiency Rating

Frequency Rating

Carotids/Neck *

Carotids/Neck proficiency*

Carotids/Neck frequency*

Renal Arteries *

Renal Arteries proficiency*

Renal Arteries frequency*

Pelvis *

Pelvis proficiency*

Pelvis frequency*

Upper & Lower Extremities *

Upper & Lower Extremities proficiency*

Upper & Lower Extremities frequency*

Carotids/Neck *

Carotids/Neck proficiency*

Carotids/Neck frequency*

MR Studies

Proficiency Rating

Frequency Rating

Cardiac MRI *

Cardiac MRI proficiency*

Cardiac MRI frequency*

Head/Neck *

Head/Neck proficiency*

Head/Neck frequency*

Brain/Head w-w/o Contrast *

Brain/Head w-w/o Contrast proficiency*

Brain/Head w-w/o Contrast frequency*

Face w-w/o Contrast *

Face w-w/o Contrast proficiency*

Face w-w/o Contrast frequency*

Pituitary w-w/o Contrast *

Pituitary w-w/o Contrast proficiency*

Pituitary w-w/o Contrast frequency*

Soft Tissue Neck w-w/o Contrast *

Soft Tissue Neck w-w/o Contrast proficiency*

Soft Tissue Neck w-w/o Contrast frequency*

TMJ w-w/o Contrast *

TMJ w-w/o Contrast proficiency*

TMJ w-w/o Contrast frequency*

Breast *

Breast proficiency*

Breast frequency*

Abdomen/Pelvis

Proficiency Rating

Frequency Rating

Abdomen w-w/o Contrast *

Abdomen w-w/o Contrast proficiency*

Abdomen w-w/o Contrast frequency*

Adrenals w-w/o Contrast *

Adrenals w-w/o Contrast proficiency*

Adrenals w-w/o Contrast frequency*

Cholangiogram *

Cholangiogram proficiency*

Cholangiogram frequency*

Pelvis w-w/o Contrast *

Pelvis w-w/o Contrast proficiency*

Pelvis w-w/o Contrast frequency*

Sacroiliac Joint w-w/o Contrast *

Sacroiliac Joint w-w/o Contrast proficiency*

Sacroiliac Joint w-w/o Contrast frequency*

Renal w-w/o Contrast *

Renal w-w/o Contrast proficiency*

Renal w-w/o Contrast frequency*

Enterography *

Enterography proficiency*

Enterography frequency*

Chest

Proficiency Rating

Frequency Rating

Brachial Plexus *

Brachial Plexus proficiency*

Brachial Plexus frequency*

Breast w-w/o Contrast *

Breast w-w/o Contrast proficiency*

Breast w-w/o Contrast frequency*

Chest w-w/o Contrast *

Chest w-w/o Contrast proficiency*

Chest w-w/o Contrast frequency*

Sternum w-w/o Contrast *

Sternum w-w/o Contrast proficiency*

Sternum w-w/o Contrast frequency*

Spine

Proficiency Rating

Frequency Rating

Cervical Spine w-w/o Contrast *

Cervical Spine w-w/o Contrast proficiency*

Cervical Spine w-w/o Contrast frequency*

Thoracic Spine w-w/o Contrast *

Thoracic Spine w-w/o Contrast proficiency*

Thoracic Spine w-w/o Contrast frequency*

Lumbar Spine w-w/o Contrast *

Lumbar Spine w-w/o Contrast proficiency*

Lumbar Spine w-w/o Contrast frequency*

Sacrum w-w/o Contrast *

Sacrum w-w/o Contrast proficiency*

Sacrum w-w/o Contrast frequency*

Upper Extremities

Proficiency Rating

Frequency Rating

Scapula w-w/o Contrast *

Scapula w-w/o Contrast proficiency*

Scapula w-w/o Contrast frequency*

Shoulder w-w/o Contrast *

Shoulder w-w/o Contrast proficiency*

Shoulder w-w/o Contrast frequency*

Arthogram *

Arthogram proficiency*

Arthogram frequency*

Elbow/Wrist w-w/o Contrast *

Elbow/Wrist w-w/o Contrast proficiency*

Elbow/Wrist w-w/o Contrast frequency*

Hand/Finger w-w/o Contrast *

Hand/Finger w-w/o Contrast proficiency*

Hand/Finger w-w/o Contrast frequency*

Humerus w-w/o Contrast *

Humerus w-w/o Contrast proficiency*

Humerus w-w/o Contrast frequency*

Lower Extremities

Proficiency Rating

Frequency Rating

Hip w-w/o Contrast *

Hip w-w/o Contrast proficiency*

Hip w-w/o Contrast frequency*

Knee w-w/o Contrast *

Knee w-w/o Contrast proficiency*

Knee w-w/o Contrast frequency*

Foot/Ankle w-w/o Contrast *

Foot/Ankle w-w/o Contrast proficiency*

Foot/Ankle w-w/o Contrast frequency*

Femur/Tibia w-w/o Contrast *

Femur/Tibia w-w/o Contrast proficiency*

Femur/Tibia w-w/o Contrast frequency*

Phase Array

Proficiency Rating

Frequency Rating

Head *

Head proficiency*

Head frequency*

Neurovascular *

Neurovascular proficiency*

Neurovascular frequency*

Spine *

Spine proficiency*

Spine frequency*

Torso *

Torso proficiency*

Torso frequency*

Surface Coils

Proficiency Rating

Frequency Rating

Extremity *

Extremity proficiency*

Extremity frequency*

Shoulder *

Shoulder proficiency*

Shoulder frequency*

TMJ *

TMJ proficiency*

TMJ frequency*

Images

Proficiency Rating

Frequency Rating

Echo Planar Imaging - EPI *

Echo Planar Imaging - EPI proficiency*

Echo Planar Imaging - EPI frequency*

Gradient Echo Imaging *

Gradient Echo Imaging proficiency*

Gradient Echo Imaging frequency*

Multiplanar Reconstruction/MRA *

Multiplanar Reconstruction/MRA proficiency*

Multiplanar Reconstruction/MRA frequency*

Spin Echo Images *

Spin Echo Images proficiency*

Spin Echo Images frequency*

T-1 Weighted *

T-1 Weighted proficiency*

T-1 Weighted frequency*

T-2 Weighted *

T-2 Weighted proficiency*

T-2 Weighted frequency*

Inversion Recovery *

Inversion Recovery proficiency*

Inversion Recovery frequency*

Fat Suppression *

Fat Suppression proficiency*

Fat Suppression frequency*

Fiesta *

Fiesta proficiency*

Fiesta frequency*

MRI Imaging Systems

Proficiency Rating

Frequency Rating

Diasonics *

Diasonics proficiency*

Diasonics frequency*

Fonar *

Fonar proficiency*

Fonar frequency*

GE *

GE proficiency*

GE frequency*

Hitachi *

Hitachi proficiency*

Hitachi frequency*

Philips *

Philips proficiency*

Philips frequency*

Siemens *

Siemens proficiency*

Siemens frequency*

Technicare *

Technicare proficiency*

Technicare frequency*

Toshiba *

Toshiba proficiency*

Toshiba frequency*

All Tech Medical Systems *

All Tech Medical Systems proficiency*

All Tech Medical Systems frequency*

Anke *

Anke proficiency*

Anke frequency*

Aspect Imaging *

Aspect Imaging proficiency*

Aspect Imaging frequency*

Aurora *

Aurora proficiency*

Aurora frequency*

Neusoft *

Neusoft proficiency*

Neusoft frequency*

Paramed *

Paramed proficiency*

Paramed frequency*

Esaote *

Esaote proficiency*

Esaote frequency*

Time Medical Systems *

Time Medical Systems proficiency*

Time Medical Systems frequency*

Professional Knowledge and Skills

Proficiency Rating

Frequency Rating

Computerized Charting *

Computerized Charting proficiency*

Computerized Charting frequency*

Venipuncture *

Venipuncture proficiency*

Venipuncture frequency*

Contrast Administration *

Contrast Administration proficiency*

Contrast Administration frequency*

Imaging a Patient with Conscious Sedation *

Imaging a Patient with Conscious Sedation proficiency*

Imaging a Patient with Conscious Sedation frequency*

Imaging a Patient under Anesthesia *

Imaging a Patient under Anesthesia proficiency*

Imaging a Patient under Anesthesia frequency*

Patient Isolation/Infection Prevention *

Patient Isolation/Infection Prevention proficiency*

Patient Isolation/Infection Prevention frequency*

Certifications/Licensures/Regis *

Certifications/Licensures/Regis proficiency*

Certifications/Licensures/Regis frequency*

National Patient Safety Goals

Proficiency Rating

Frequency Rating

Accurate Patient Identification *

Accurate Patient Identification proficiency*

Accurate Patient Identification frequency*

Effective Communication *

Effective Communication proficiency*

Effective Communication frequency*

Infection Control *

Infection Control proficiency*

Infection Control frequency*

Universal Precautions *

Universal Precautions proficiency*

Universal Precautions frequency*

Patients in Isolation *

Patients in Isolation proficiency*

Patients in Isolation frequency*

Minimize Risk for Fall *

Minimize Risk for Fall proficiency*

Minimize Risk for Fall frequency*

Work Settings

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*

Level I Trauma *

Level I Trauma proficiency*

Level I Trauma frequency*

Level II Trauma *

Level II Trauma proficiency*

Level II Trauma frequency*

Outpatient Clinic/Free-Standing Clinic *

Outpatient Clinic/Free-Standing Clinic proficiency*

Outpatient Clinic/Free-Standing Clinic frequency*

Mobile *

Mobile proficiency*

Mobile frequency*

Supervisory/Management Experience *

Supervisory/Management Experience proficiency*

Supervisory/Management Experience frequency*

Equipment

Proficiency Rating

Frequency Rating

GE *

GE proficiency*

GE frequency*

Hitachi *

Hitachi proficiency*

Hitachi frequency*

Philips *

Philips proficiency*

Philips frequency*

Siemens *

Siemens proficiency*

Siemens frequency*

Toshiba *

Toshiba proficiency*

Toshiba frequency*

Computer Systems

Proficiency Rating

Frequency Rating

Epic *

Epic proficiency*

Epic frequency*

Meditech *

Meditech proficiency*

Meditech frequency*

Cerner *

Cerner proficiency*

Cerner frequency*

Pacs *

Pacs proficiency*

Pacs frequency*

McKesson *

McKesson proficiency*

McKesson frequency*

Centricity *

Centricity proficiency*

Centricity frequency*

Certify your information*

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Date*

Skills/Competences

Proficiency

Frequency

MRI TECHNOLOGIST

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