SELF EVALUATION
RADIATION THERAPY 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:
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Years Experience: yrs. |
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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 = |
H ighly Proficient.Extensively experienced; able to supervise and/or train others. |
SE = |
Some Experience. |
|
| VE = |
Very Experienced. |
NE = | No Experience. | |
| EX = |
Experienced. |
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| TREATMENT SETUPS: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | ||
| Tangent Chestwall | Penis/Scrotum/Testes w/Shields | |||||||||||
| Tangent Breast | Pituitary Gland | |||||||||||
| 1) SSD/SAD – 2 Fields | Whole Body Irradiation | |||||||||||
| 2) SSD/SAD – 3 Fields | Mycosis Fungoides | |||||||||||
| 3) +AP Supraclav+PAB | Larynx | |||||||||||
| 2 Field Pelvis/Prostate | Moving Field/Whole CNS | |||||||||||
| 4 Field Pelvis/Prostate | Mixed Beam- | |||||||||||
| 7 Field Pelvis/Prostate | Photon/Electron Match | |||||||||||
| ARC/Rotational Pelvis/Prostate | Prone Colorectal | |||||||||||
| 2 Field Lung | Prone Esophagus | |||||||||||
| Oblique/Off Cord Lung | Orbit with Hanging Block | |||||||||||
| Full Mantle | Superior Vena Cava | |||||||||||
| 3 Field Head and Neck | Spinal Cord Compression | |||||||||||
| Whole Brain/Hand-Eye Block | C-Spine with Patient in Halo | |||||||||||
| Whole Brain/German Helmet | Other Specialty Set-ups: | |||||||||||
| Inverted Y Field | ||||||||||||
| Hockeystick Field | ||||||||||||
| TREATMENT | HP | VE | EX | SE | NE | SIMULATORS: | HP | VE | EX | SE | NE | |
| ACCELERATORS: | Kermath | |||||||||||
| Varian 4-100 | Ximatron | |||||||||||
| Varian 6-100 | Toshiba | |||||||||||
| Varian D.E. 6/18 | Philips | |||||||||||
| Varian 2100 C | Varian 2100 | |||||||||||
| Varian 2100 CD MLC | Oldelft | |||||||||||
| Siemens D.E. 6/15 | AECL | |||||||||||
| Siemens D.E. 6/18 | Cascade | |||||||||||
| Philips Units | Other: | |||||||||||
| General Electric Units | Other: | |||||||||||
| Other: | Other: | |||||||||||
| SUPERFICIAL UNITS: | HP | VE | EX | SE | NE | MISC. EQUIPMENT: | HP | VE | EX | SE | NE | |
| General Electric | Cobalt-60 Units-Theratron | |||||||||||
| Other: | Hyperthermia Units | |||||||||||
| Any Accelerators w/Beamstopper | ||||||||||||
| H.D.R. UNITS: | Other: | |||||||||||
| Nucletron | ||||||||||||
| Other: | RECORD & VERIFY SYSTEMS: | |||||||||||
| Varis–Varian | ||||||||||||
| FILM PROCESSORS: | Lantis–Siemens | |||||||||||
| Kodak | Impac–Siemens | |||||||||||
| Other: | Philips–Philips | |||||||||||
| FABRICATION OF | MISC. SKILLS: | |||||||||||
| IMMOBILIZATION DEVICES: | Photon Hand Calculations | |||||||||||
| Cerrobend Blocks | Electron Hand Calculations | |||||||||||
| Electron Blocks | Standard Portal Films | |||||||||||
| Alpha Cradles | Orthogonial Protal Films | |||||||||||
| Aqua Plast Masks | Patient Tatooing | |||||||||||
| Brass Step Compensators | Morning Treatment Unit Warmup | |||||||||||
| Custom Wax Forms | Morning Simulator Warmup | |||||||||||
| Vacuum Formed Masks | Quality Assurance | |||||||||||
| Intraoral Biteblocks | Accelerator Checks | |||||||||||
| Vacuum Cradles | Accelerator Output Checks | |||||||||||
| Plaster Strip Masks | Other: | |||||||||||
Submitted by: Date:
© Rapid Temps, Inc., rev 12-99
