Radiation Therapy - Dosimetry Skills Checklist

		Radiation Therapy - Dosimetry Skills Checklist
NAME

LAST 4 OF SSN

DATE

	I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
Proficiency Scale:	1 = No Experience 2 = Need Training 3 = Able to perform with supervision 4 = Able to perform independently

Rating Stars (Click)	BACKGROUND		1	2	3	4
	Cancer Center
	Clinic
	Hospital
	Management Experience
	Teaching / Educational
	Applications
Rating Stars (Click)	TITLES / POSITIONS		1	2	3	4
	ARRT Registered Radiation Therapist
	Registry Eligible Radiation Therapist
	Simulation Technologist
	ABMD Certified Medical Dosimetrist
	Medical Dosimetrist (Board Eligible)
	ABMP Certified Medical Physicist
	ABR Certified Medical Physicist
	Medical Physicist (MS)
	Medical Physicist (PhD)
	Jr. Medical Physicist
Rating Stars (Click)	PROCEDURES		1	2	3	4
	Brachytherapy - HDR / LDR
	Block Cutting
	Custom Molds
	Dosimetry
	Hand Calculations
	Electronic Portal Imaging
	Hyperthermia Treatment
	IMRT (Intensity Modulated Radiotherapy)
	Leksell Gamma Knife
	Respiratory Gating
	Simulations
	Stereotatic Radiotherapy
	Stereotactic Radiosurgery
	Superficial Radiation Treatment
	Superficial Orthovoltage
	Treatment Planning
	MLC (multileaf collimator)
	DMLC (dynamic multileaf collimator)
	MIMiC (multileaf intensity-modulating collimator)
	BAT-Ultrasound Localization
	Tomotherapy
Rating Stars (Click)	MOLD ROOM		1	2	3	4
	Huestis Block Cutter
	Diacor Portalcast
Rating Stars (Click)	TREATMENT PLANNING SYSTEMS		1	2	3	4
	ADAC
	ADAC Pinnacle - 3D
	AECL / Theratronics Theraplan
	ATC
	Atronix PC 12
	Capintec TR 108
	CMS
	CMS Focus - 3D
	Elekta Precise
	Elekta RENDER
	G.E. R/T Plan
	Helax TMS
	Helios
	MDDCS
	MMS
	Modulex
	Multidata
	Mulidata DSS
	Nomus Corvus 3D
	NOMOS Peacock
	Nucletron Plato
	Picker ACQPlan 3D
	Prowess 3D
	PTI
	P-Z Sim
	RAD 8
	RADPLANS-6
	RAHD
	RAHD 3D/ Pro
	ROCS - 2D
	ROCS-3D
	Siemens
	Siemens IMFAST
	Thera Pac
	Toshiba
	Varian Cadplan
	Varian Eclipse
	Varian R07
	Varian SomaVision
	VAX 11/780
	Trs 80
Rating Stars (Click)	SUPERFICIAL / ORTHOVOLTAGE		1	2	3	4
	GE 120 KVP
	GE Maximar 250
	Keleket 250
	Maxitron 300
	Philips RT-50
	Philips RT-100
	Philips RT-100
	Picker
	Siemens
Rating Stars (Click)	TREATMENT UNITS		1	2	3	4
	Allis Chalmers 25 MeV Betatron
	ATC 6
	Betatron
	EMI-4
	Mitsubishi EXL
	Philips Elekta Sli
	Philips Elekta SLi15
	Philips Elekta SL15
	Philips SL18
	Philips Elekta SL25
	Philips Elekta SL75-5
	Philips Elekta SL75-6
	Philips Elekta SL75-10
	Philips SL75-14
	Philips SL75-20
	Siemens 4 MeV
	Siemens 6 MeV
	Siemens 12 MeV
	Siemens 1.5T Helicon
	Siemens 1.5T Vision
	Siemens KD & KD2
	Siemens MD & MD2
	Siemens Mevatron 20
	Siemens Mevatron 67
	Siemens Mevatron 77
	Siemens PRIMUS
	Siemens PRIMART
	Siemens PRIMATOM
	Siemens Oncor
	Toshiba LMR 15
	Toshiba LMR 4
	Varian Clinac 6EX
	Varian Clinac 21 EX
	Varian Clinac 23 EX
	Varian Clinac 600
	Varian Clinac 600 C/D
	Varian Clinac 2100 C/D
	Varian Clinac 2100 C/D with MLC
	Varian Clinac 2300 C/D
	Varian 2500 C
	Silhouette Edition Clinac
	Varian 6/100
	Varian 1800 C
	Varian 4 MeV
	Varian 6 MeV
	Varian 18 MeV
	Varian 20 MeV
	Varian 35 MeV
Rating Stars (Click)	SIMULATORS		1	2	3	4
	6F Simulator
	AECL Therasim 750
	ATC
	Cascade
	GE HiSpeed
	Kermath
	Oldelft
	Philips / Elekta
	Picker ACQSim
	Picker Ther-X
	Siemens
	Siemens PRIMATOM
	Simulix-HP
	Siemens SIMVIEW
	SmartSim
	Siemens SOMATOM
	Elekta PreciseSIM
	Toshiba
	Toshiba LX7
	Varian Ximatron
	Ximatron
Rating Stars (Click)	RECORD & VERIFY SYSTEMS		1	2	3	4
	IMPAC
	LANTIS
	PortalVision
	Varian RMS
	VARiS
	Veriflex
	ARIA
Rating Stars (Click)	BRACHYTHERAPY		1	2	3	4
	BrachyVision
	Gamma Med
	HDR Applicator
	Nucletron
	SmartSeed
	VariSeed
	ARIA
Rating Stars (Click)	HYPERTHERMIA		1	2	3	4
	BSD
	Clinitherm
Rating Stars (Click)	COBALT MACHINES		1	2	3	4
	AECL Cobalt
	AECL Eldorado 6
	AECL Eldorado 8
	AECL Eldorado 80
	AECL Eldorado 780
	AECL Theratron 80
	Picker C-9
	Picker V-9
	RCR 120-C-3
	Siemens Gamatron S
	TEM
	Theratron
Rating Stars (Click)	EMR		1	2	3	4
	Epic
	Cerner
	Eclipsys
	McKesson
	Meditech
	Other Computerized System
	Computerized Physician Order Entry
	Bar Coding for Medication Administration
MY EXPERIENCE IS PRIMARILY IN:
Unit	No. of Years	Unit	No. of Years
BURN		POST PARTUM
CRITICAL UNIT		LABOR & DELIVERY
PACU		NEWBORN NURSERY
NEUROLOGY		LEVEL II NICU
TELEMETRY		LEVEL III NICU
MEDICAL		PICU
SURGICAL		PEDIATRICS
ONCOLOGY		OB/GYN
ORTHOPEDICS		PSYCHIATRY
OPERATING ROOM		RRT
EMERGENCY ROOM		CRT
TRAUMA CENTER LEVEL 1
COMMUNITY ER
RURAL ER
Rating Stars (Click)	Age Specific Competencies		1	2	3	4
	Newborn/Neonatal (birth – 30 days)
	Infant (30 days-1 year)
	Toddler (1-3 years)
	Preschool (3-5 years)
	School Age Children (5-12 years)
	Adolescent (12-17 years)
	Young Adults (18-44 years)
	Middle Adults (45-64 years)
	Older Adults (>65 years)