SELF EVALUATION
ECHOCARDIOGRAPHY
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.
ADULT ECHOCARDIOGRAPHY: HP VE EX SE NE
2-D
M-Mode
Pulsed Wave Doppler
Continuous Wave Doppler
Color Doppler
Pedoff Probe
PEDIATRIC ECHOCARDIOGRAPHY: HP VE EX SE NE
2-D
M-Mode
Pulsed Wave Doppler
Continuous Wave Doppler
Color Doppler
Pedoff Probe
TRANSESOPHOGEAL HP VE EX SE NE
ECHOCARDIOGRAPHY:
STRESS
ECHOCARDIOGRAPHY:		 HP VE EX SE NE
Exercise
Pharmacological
Other:
Other:
STRESS EKG WITH TREADMILL TESTING:
DOBUTAMINE STRESS ECHOCARDIOGRAPHY:
2d
Pulsed Wave Doppler
Continuous Wave Doppler
Color Doppler
Pedoff Probe
BIOPSY:
BUBBLE STUDIES:
LIST EQUIPMENT USED AND ADDITIONAL ECHOCARDIOGRAPHY SKILLS: 
Submitted by:      Date:

    

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