SELF EVALUATION
DOSIMETRY TECHNOLOGY
SKILLS PROFICIENCY CHECKLIST
Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE, Albuquerque, NM 87109 
     Last Name: 
    First Name: 
Middle Initial: 
 Years Experience

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.

PROFICIENCY LEVEL

PROFICIENCY LEVEL

DOSIMETRY SKILLS:

HP

VE

EX

SE

NE

  

HP

VE

EX

SE

NE

TREATMENT PLANNING SYSTEMS

ADAC

HDR

CMS FOCUS

VARIAN

RAHD

NUCLETRON

THERAPLAN

GAMA MED

ROCS

            

GE

IMRT

CAD PLAN

ADAC

ECLIPSE

CORVUS

PLATO

CMS

RENDER PLAN

PLATO

PROWESS

RADIONICS

AcUPLAN

            

TREATMENT PLANNING

3D

HP

VE

EX

SE

NE

2D

HP

VE

EX

SE

NE

CT SIMULATIONS

IRREG FIELDS

BREASTS

CONTOURS

PROSTATES

            

LUNG

RECORD AND VERIFY

          

HEAD AND NECK

IMPAC

PELVIS

VARIS

MANTLE

            

FUSIONS

FILMLESS

          

MLC

PROTAL IMAGING

DYNAMIC WEDGES

KODAK

OTHER AREAS OF SKILL

HP

VE

EX

SE

NE

EQUIPMENT USED:

HP

VE

EX

SE

NE
(1) (1)
(2) (2)
(3) (3) 
Submitted by:      Date: 
Phone / Email:

Proceed to the Application.

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