SELF EVALUATION
CT SKILLS PROFICIENCY CHECKLIST

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If you prefer, you can print a form to fax or mail.

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     Last Name: 
    First Name: 
Middle Initial: 
Years Experience: yrs.

DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.

LEVELS OF PROFICIENCY KEY:

HP =

Highly Proficient.
Extensively experienced; able to supervise and/or train others.

 SE =

Some Experience.
Need review and assistance or supervision.
VE =

Very Experienced.
Can perform well without assistance or supervision.

 NE = No Experience.
EX =

Experienced.
Competent; can perform independently; may need initial review or supervision.
ROUTINE STUDIES: HP VE EX SE NE HP VE EX SE NE
Brain with Contrast Abdomen
Brain without Contrast Liver
TMJ’s Renal
Temporal Bones Hemangioma
Orbits Pancreas
Sinuses Pelvis
Sella Calculus
Facial Bones Upper Extremities
Neck (ST) Lower Extremities
Larynx Cervical Spine
Chest Thoracic Spine
Pulmonary Embolism Lumbar Spine
HARDWARE: HP VE EX SE NE PRESSURE INJECTORS: HP VE EX SE NE
GE Medrad
Hilight Advantage L/F
Highspeed Advantage Venipuncture
Pro Speed
CT/I SPECIAL PROCEDURES: HP VE EX SE NE
Light Speed CT/I Biopsy Procedures
Siemens Angio
Picker Stereotactic Brain
Toshiba Bone Marrow Density 
Submitted by:      Date:

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