SELF EVALUATION
MAMMOGRAPHY SKILLS PROFICIENCY CHECKLISTT

Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE Albuquerque, NM 87109 
NAME: _____________________________________
      Last           First          M.I.
 
Years Experience: _____ years

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.
EQUIPMENT: HP VE EX SE NE PROCEDURES: HP VE EX SE NE
Siemens Breast Localization
Phillips Ductogram
Lo-Rad Galactogram
Picker Stereotactic Core Biopsy
Bennett Contour Specimen Imaging
G.E. Other:
Toshiba Other:
Other:

Other:

QC TESTS: HP VE EX SE NE ROUTINE EXAMS: HP VE EX SE NE
Daily Processor Strips C.C.
Phantom Images MLO
Darkroom Fog Test 90o Lateral
Compression Test CV (Cleavage)
Screen/Film Contact Spot Compression
Repeat Analysis Spot Magnification
Fixer Retention LMO
Crossover Procedure Roll view
Weekly QC Checklists
Quarterly QC Checklists CONTINUOUS EXAMS:
Biannual QC Checklists XCCL
PT Tracking Reports Axillary Tail
Other:

Tangential
Other: Eckluno Views for Breast
Other: Augmentation 
 
Signature: ___________________________     Date: _________________
Phone / Email: ___________________________

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