Nuclear Medicine Technologist

NUCLEAR MEDICINE 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*

Head & Neck

Proficiency Rating

Frequency Rating

Brain *

Brain proficiency*

Brain frequency*

Cerebral Blood Flow *

Cerebral Blood Flow proficiency*

Cerebral Blood Flow frequency*

Carotid Artery *

Carotid Artery proficiency*

Carotid Artery frequency*

Shunt Patency *

Shunt Patency proficiency*

Shunt Patency frequency*

Ventricular Shunt *

Ventricular Shunt proficiency*

Ventricular Shunt frequency*

Abdominal Shunt *

Abdominal Shunt proficiency*

Abdominal Shunt frequency*

Cisternography *

Cisternography proficiency*

Cisternography frequency*

Brain with Glucoheptonate *

Brain with Glucoheptonate proficiency*

Brain with Glucoheptonate frequency*

Gated SPECT (Post Infarct) *

Gated SPECT (Post Infarct) proficiency*

Gated SPECT (Post Infarct) frequency*

Dacrocystography *

Dacrocystography proficiency*

Dacrocystography frequency*

Salivary Glands *

Salivary Glands proficiency*

Salivary Glands frequency*

Thyroid/Thyroid Ablation *

Thyroid/Thyroid Ablation proficiency*

Thyroid/Thyroid Ablation frequency*

Parathyroid *

Parathyroid proficiency*

Parathyroid frequency*

Thyroid Cancer Survey *

Thyroid Cancer Survey proficiency*

Thyroid Cancer Survey frequency*

Uptake Scan *

Uptake Scan proficiency*

Uptake Scan frequency*

Skeletal/Bone

Proficiency Rating

Frequency Rating

Three-Phase *

Three-Phase proficiency*

Three-Phase frequency*

Whole Body *

Whole Body proficiency*

Whole Body frequency*

Limited *

Limited proficiency*

Limited frequency*

Bone Marrow Scan *

Bone Marrow Scan proficiency*

Bone Marrow Scan frequency*

Cardiac

Proficiency Rating

Frequency Rating

Myocardial Gated SPECT *

Myocardial Gated SPECT proficiency*

Myocardial Gated SPECT frequency*

Infarction *

Infarction proficiency*

Infarction frequency*

Exercise/Rest-Single *

Exercise/Rest-Single proficiency*

Exercise/Rest-Single frequency*

Exercise/Rest-Multiple *

Exercise/Rest-Multiple proficiency*

Exercise/Rest-Multiple frequency*

Persantine/Thallium *

Persantine/Thallium proficiency*

Persantine/Thallium frequency*

Wall Motion *

Wall Motion proficiency*

Wall Motion frequency*

Cardiac First Pass *

Cardiac First Pass proficiency*

Cardiac First Pass frequency*

Gated Blood Pool Studies *

Gated Blood Pool Studies proficiency*

Gated Blood Pool Studies frequency*

Myocardial Perfusion *

Myocardial Perfusion proficiency*

Myocardial Perfusion frequency*

Dual Isotopes *

Dual Isotopes proficiency*

Dual Isotopes frequency*

Adenosine Infusion *

Adenosine Infusion proficiency*

Adenosine Infusion frequency*

Vena Cava Imaging *

Vena Cava Imaging proficiency*

Vena Cava Imaging frequency*

CCK Ejection Fraction *

CCK Ejection Fraction proficiency*

CCK Ejection Fraction frequency*

MUGA Scan *

MUGA Scan proficiency*

MUGA Scan frequency*

Lung & Chest

Proficiency Rating

Frequency Rating

VQ Ventilation/Perfusion *

VQ Ventilation/Perfusion proficiency*

VQ Ventilation/Perfusion frequency*

Aerosol Lung Scan *

Aerosol Lung Scan proficiency*

Aerosol Lung Scan frequency*

Breast *

Breast proficiency*

Breast frequency*

Abdomen, GI & GU

Proficiency Rating

Frequency Rating

GI reflux *

GI reflux proficiency*

GI reflux frequency*

Gastric Emptying *

Gastric Emptying proficiency*

Gastric Emptying frequency*

GI Bleeding *

GI Bleeding proficiency*

GI Bleeding frequency*

Meckels Diverticulum *

Meckels Diverticulum proficiency*

Meckels Diverticulum frequency*

Liver *

Liver proficiency*

Liver frequency*

Liver with Flow *

Liver with Flow proficiency*

Liver with Flow frequency*

Gallbladder *

Gallbladder proficiency*

Gallbladder frequency*

HIDA and CCK-HIDA Scan (Cholescintigraphy) *

HIDA and CCK-HIDA Scan (Cholescintigraphy) proficiency*

HIDA and CCK-HIDA Scan (Cholescintigraphy) frequency*

Biliary Function *

Biliary Function proficiency*

Biliary Function frequency*

Liver/Spleen *

Liver/Spleen proficiency*

Liver/Spleen frequency*

Liver Hemangioma *

Liver Hemangioma proficiency*

Liver Hemangioma frequency*

Spleen *

Spleen proficiency*

Spleen frequency*

Renogram *

Renogram proficiency*

Renogram frequency*

With Lasix *

With Lasix proficiency*

With Lasix frequency*

Flow/Function *

Flow/Function proficiency*

Flow/Function frequency*

Three-Phase *

Three-Phase proficiency*

Three-Phase frequency*

Cystography *

Cystography proficiency*

Cystography frequency*

Adrenal Scan *

Adrenal Scan proficiency*

Adrenal Scan frequency*

Testicular *

Testicular proficiency*

Testicular frequency*

Endocrine/ Lymphatic/ Tumors

Proficiency Rating

Frequency Rating

Lymphatic Scan Melanoma *

Lymphatic Scan Melanoma proficiency*

Lymphatic Scan Melanoma frequency*

Injection Lymphatic *

Injection Lymphatic proficiency*

Injection Lymphatic frequency*

Lymphoscintigraphy *

Lymphoscintigraphy proficiency*

Lymphoscintigraphy frequency*

Monoclonal Antibodies *

Monoclonal Antibodies proficiency*

Monoclonal Antibodies frequency*

WBC Scan *

WBC Scan proficiency*

WBC Scan frequency*

Galliam Scan *

Galliam Scan proficiency*

Galliam Scan frequency*

Abscess Localization *

Abscess Localization proficiency*

Abscess Localization frequency*

Whole Body *

Whole Body proficiency*

Whole Body frequency*

Individual Sites *

Individual Sites proficiency*

Individual Sites frequency*

Positron Imaging/PET Scan *

Positron Imaging/PET Scan proficiency*

Positron Imaging/PET Scan frequency*

Other Procedures

Proficiency Rating

Frequency Rating

Brachytherapy *

Brachytherapy proficiency*

Brachytherapy frequency*

Hot Lab *

Hot Lab proficiency*

Hot Lab frequency*

Planar Procedures *

Planar Procedures proficiency*

Planar Procedures frequency*

SPECT Procedures *

SPECT Procedures proficiency*

SPECT Procedures frequency*

Radionuclide Arteriogram *

Radionuclide Arteriogram proficiency*

Radionuclide Arteriogram frequency*

Radionuclide Venogram *

Radionuclide Venogram proficiency*

Radionuclide Venogram frequency*

Schillings Test *

Schillings Test proficiency*

Schillings Test frequency*

Indium111 *

Indium111 proficiency*

Indium111frequency*

I123 Uptake Scan *

I123 Uptake Scan proficiency*

I123 Uptake Scan frequency*

I131 Therapy *

I131 Therapy proficiency*

I131 Therapy frequency*

Stress Holter Monitoring *

Stress Holter Monitoring proficiency*

Stress Holter Monitoring frequency*

Gated NVG Stress *

Gated NVG Stress proficiency*

Gated NVG Stress frequency*

Gated NVG Rest *

Gated NVG Rest proficiency*

Gated NVG Rest frequency*

Radio Pharmaceutical Prep *

Radio Pharmaceutical Prep proficiency*

Radio Pharmaceutical Prep frequency*

Zevalin Treatment *

Zevalin Treatment proficiency*

Zevalin Treatment frequency*

Wipe Test *

Wipe Test proficiency*

Wipe Test frequency*

ALARA (As Low As Reasonably Achievable) *

ALARA (As Low As Reasonably Achievable) proficiency*

ALARA (As Low As Reasonably Achievable) frequency*

Equipment

Proficiency Rating

Frequency Rating

Siemens Computer *

Siemens Computer proficiency*

Siemens Computer frequency*

Siemens Diacam *

Siemens Diacam proficiency*

Siemens Diacam frequency*

Siemens Orbiter Camera *

Siemens Orbiter Camera proficiency*

Siemens Orbiter Camera frequency*

Siemens Spect *

Siemens Spect proficiency*

Siemens Spect frequency*

Summit (SMV) *

Summit (SMV) proficiency*

Summit (SMV) frequency*

ADAC Computer *

ADAC Computer proficiency*

ADAC Computer frequency*

ADAC Camera *

ADAC Camera proficiency*

ADAC Camera frequency*

3D Reconstruction Packet *

3D Reconstruction Packet proficiency*

3D Reconstruction Packet frequency*

Centiview *

Centiview proficiency*

Centiview frequency*

Digital Computer *

Digital Computer proficiency*

Digital Computer frequency*

Elscint Camera *

Elscint Camera proficiency*

Elscint Camera frequency*

GE LFOV *

GE LFOV proficiency*

GE LFOV frequency*

GE MAXI 400 Camera *

GE MAXI 400 Camera proficiency*

GE MAXI 400 Camera frequency*

GE Star Cam SPECT *

GE Star Cam SPECT proficiency*

GE Star Cam SPECT frequency*

GE Star 1 Computer *

GE Star 1 Computer proficiency*

GE Star 1 Computer frequency*

GE Star Cam Computer *

GE Star Cam Computer proficiency*

GE Star Cam Computer frequency*

Genesis *

Genesis proficiency*

Genesis frequency*

Genesis Computer *

Genesis Computer proficiency*

Genesis Computer frequency*

Hitachi *

Hitachi proficiency*

Hitachi frequency*

MDS Camera Medispect *

MDS Camera Medispect proficiency*

MDS Camera Medispect frequency*

MDS Medispect *

MDS Medispect proficiency*

MDS Medispect frequency*

Omega 500 *

Omega 500 proficiency*

Omega 500 frequency*

Omega 500 Computer *

Omega 500 Computer proficiency*

Omega 500 Computer frequency*

Phillips *

Phillips proficiency*

Phillips frequency*

PhoGamma IV *

PhoGamma IV proficiency*

PhoGamma IV frequency*

Picker *

Picker proficiency*

Picker frequency*

Picker Prism *

Picker Prism proficiency*

Picker Prism frequency*

Toshiba 6000 *

Toshiba 6000 proficiency*

Toshiba 6000 frequency*

ZLC *

ZLC proficiency*

ZLC frequency*

General Skills

Proficiency Rating

Frequency Rating

Patients in Restraints *

Patients in Restraints proficiency*

Patients in Restraints frequency*

Lifting/Transfer Devices *

Lifting/Transfer Devices proficiency*

Lifting/Transfer Devices frequency*

Cardiac Arrest/CPR *

Cardiac Arrest/CPR proficiency*

Cardiac Arrest/CPR frequency*

Use of Rapid Response Teams *

Use of Rapid Response Teams proficiency*

Use of Rapid Response Teams frequency*

Universal Precautions *

Universal Precautions proficiency*

Universal Precautions frequency*

Working with Patient Under Conscious Sedation *

Working with Patient Under Conscious Sedation proficiency*

Working with Patient Under Conscious Sedation frequency*

Patient / Family Teaching of Procedures *

Patient / Family Teaching of Procedures proficiency*

Patient / Family Teaching of Procedures frequency*

Crash Carts *

Crash Carts proficiency*

Crash Carts 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*

ER/ICU *

ER/ICU proficiency*

ER/ICU frequency*

Level I Trauma *

Level I Trauma proficiency*

Level I Trauma frequency*

Level II Trauma *

Level II Trauma proficiency*

Level II Trauma frequency*

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Skills/Competences

Proficiency

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NUCLEAR MEDICINE TECHNOLOGIST

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