SELF EVALUATION
NUCLEAR MEDICINE SKILLS PROFICIENCY CHECKLIST

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     Last Name: 
    First Name: 
Middle Initial:
BACKGROUND AND EXPERIENCE: POSITIONS HELD:
Months/Years Months/Years
Applications Registered Nuc Med Tech, NMTCB
Clinic Registry-eligible Nuc Med Tech
Doctor’s Office NM Supervisor
Hospital NM Director
Management Nuclear Cardiology Tech
Mobile Route Registered Nuc Med Tech, AART
Nuclear Cardiology Other:
Teaching/Equipment Other:

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.
 VE = Very Experienced; can perform well, without assistance or supervision.
 EX = Experienced; competent; can perform independently; may need initial review or supervision.
 SE = Some Experience; need review and assistance or supervision.
 NE = No Experience.

EQUIPMENT: HP VE EX SE NE
3-D Reconstruction Packet
ADAC Camera
ADAC Computer
Centiview
Digital Computer
Elscint Camera
GE LFOV
GE MAXI 400 Camera
GE Star Cam Spect
GE Star 1 Computer
GE Star Cam Computer
Genesis
Genesis Computer
Hepatic Hemangloma
Hitachi
MDS Camera Medispect
MDS Medispect
Micro Dot Computer
Ohio Nuclear
Ohio Nuclear 410 Camera
Omega 500  
Omega 500 Computer  
Phillips (NM)  
PhoGamma IV  
Picker (NM)  
Siemens Computer  
Siemens Diacam  
Siemens Orbiter Camera  
Siemens Spect  
Sophy Camera D57  
Sophy Computer  
Summit  
Technicare 438 Camera  
Technicare 560 Computer  
Technicare Omega 500 Camera  
Technicare Port 420  
Technicare Port 550  
Toshiba 6000  
ZLC  
Picker Prism  
PROCEDURES: HP VE EX SE NE
I-123 Uptake
I-131 Therapy
Aerosol Lung Scan
Bone Scan
Brachytherapy
Brain Scan
Cerebral Blood Flow
Gallium Scan
GI Bleeding Study
HIDA Scan
Hot Lab
Indium-111 WBC
Liver Scan
MUGA Scan
NVG Rest
NVG Stress
Persantine Thallium
PET Scanning
Radio Pharmaceutical Prep
Radionuclide Arteriogram  
Radionuclide Venogram  
Renagrams  
Renal Scan  
RIA (Radio Immuno Assay)  
Shillings  
SPECT  
Spleen Scan  
Stress Holter Monitoring  
Testicular Studies  
Thallium Stress Test  
Three Phase Renal Scan  
Thyroid Scan  
Thyroid Therapy  
Thyroid Uptake  
VP Lung Scan  
Other:  
Other:  
Other:   
Submitted by:      Date:

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