![[HRule Image]](../images/div.gif){kind=small}
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: _____ |
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 = | SE = Some
Experience; Need review and assistance or supervision. |
| VE = | Very Experienced; Can perform well, without assistance or supervision. |
NE = | NE = No Experience. |
| EX = | Experienced;
Competent; Can perform independently; May need initial review or supervision. |
| PROFICIENCY LEVEL | PROFICIENCY LEVEL | ||||||||||
| GENERAL: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | |
| Abdomen | Kidneys | ||||||||||
| Appendix | Spleen | ||||||||||
| Gall Bladder | Adrenals | ||||||||||
| Renal | Paracentisis | ||||||||||
| Biliary tree | Thorocentisis | ||||||||||
| Pancreas | Doppler of listed areas | ||||||||||
| Liver | Other | ||||||||||
| Aorta | Other | ||||||||||
|
|
|||||||||||
| OBSTETRICS AND GYNECOLOGY: |
HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | |
| 1st - 3rd Trimester Pregnancy | Interorbital Measurements | ||||||||||
| Level I | Intraorbital Measurements | ||||||||||
| Stomach | High Risk | ||||||||||
| Heart | Amniocentesis | ||||||||||
| Kidneys | Neonatal Heads | ||||||||||
| Diaphragm Bladder | Uterus | ||||||||||
| Cerebellum | Ovaries | ||||||||||
| Ventricles | Adnexa | ||||||||||
| Atria and Nuchal Fold | Transvaginal | ||||||||||
| Level II | Transabdominal Pelvic | ||||||||||
| Fingers and Toes | Doppler of listed areas | ||||||||||
| Bone Lengths | Other | ||||||||||
| Nose and Lips | Other | ||||||||||
|
|
|||||||||||
| SMALL PARTS: | HP | VE | EX | SE | NE | HP | VE | EX | SE | NE | |
| Thyroids | Superficial Masses | ||||||||||
| Breasts | Biopsies | ||||||||||
| Testicles | Doppler of listed areas | ||||||||||
| Scrotum | Other | ||||||||||
|
|
|||||||||||
Submitted by: Date:
©Rapid Temps, Inc., rev 11-00
