| 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.
|
| 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 = V
ery 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 | HP | VE | EX | SE | NE | ||
| 3-D Reconstruction Packet | Omega 500 | |||||||||||
| ADAC Camera | Omega 500 Computer | |||||||||||
| ADAC Computer | Phillips (NM) | |||||||||||
| Centiview | PhoGamma IV | |||||||||||
| Digital Computer | Picker (NM) | |||||||||||
| Elscint Camera | Siemens Computer | |||||||||||
| GE LFOV | Siemens Diacam | |||||||||||
| GE MAXI 400 Camera | Siemens Orbiter Camera | |||||||||||
| GE Star Cam Spect | Siemens Spect | |||||||||||
| GE Star 1 Computer | Sophy Camera D57 | |||||||||||
| GE Star Cam Computer | Sophy Computer | |||||||||||
| Genesis | Summit | |||||||||||
| Genesis Computer | Technicare 438 Camera | |||||||||||
| Hepatic Hemangloma | Technicare 560 Computer | |||||||||||
| Hitachi | Technicare Omega 500 Camera | |||||||||||
| MDS Camera Medispect | Technicare Port 420 | |||||||||||
| MDS Medispect | Technicare Port 550 | |||||||||||
| Micro Dot Computer | Toshiba 6000 | |||||||||||
| Ohio Nuclear | ZLC | |||||||||||
| Ohio Nuclear 410 Camera | Picker Prism | |||||||||||
| PROCEDURES: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| I-123 Uptake | Radionuclide Arteriogram | |||||||||||
| I-131 Therapy | Radionuclide Venogram | |||||||||||
| Aerosol Lung Scan | Renagrams | |||||||||||
| Bone Scan | Renal Scan | |||||||||||
| Brachytherapy | RIA (Radio Immuno Assay) | |||||||||||
| Brain Scan | Shillings | |||||||||||
| Cerebral Blood Flow | SPECT | |||||||||||
| Gallium Scan | Spleen Scan | |||||||||||
| GI Bleeding Study | Stress Holter Monitoring | |||||||||||
| HIDA Scan | Testicular Studies | |||||||||||
| Hot Lab | Thallium Stress Test | |||||||||||
| Indium-111 WBC | Three Phase Renal Scan | |||||||||||
| Liver Scan | Thyroid Scan | |||||||||||
| MUGA Scan | Thyroid Therapy | |||||||||||
| NVG Rest | Thyroid Uptake | |||||||||||
| NVG Stress | VP Lung Scan | |||||||||||
| Persantine Thallium | Other: | |||||||||||
| PET Scanning | Other: | |||||||||||
| Radio Pharmaceutical Prep | Other: | |||||||||||
Signature: ___________________________ Date: _________________
© Rapid Temps, Inc., rev 12-99
