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

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