Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
GENERAL DIAGNOSTIC
Abdomen 0 1 2
Extremities 0 1 2
Spine 0 1 2
Thoracic 0 1 2
Cervical 0 1 2
Lumbar 0 1 2
Specimen Radiographs 0 1 2
Small Bowel Series 0 1 2
Bilateral Mammograms 0 1 2
Barium Swallow 0 1 2
Barium Enema 0 1 2
Sialography 0 1 2
IVP 0 1 2
Needle Localization 0 1 2
Therapy Placement Films 0 1 2
Duodenography 0 1 2
Hysterosalpingogram 0 1 2
Angioplasty 0 1 2
Selective Angioplasty 0 1 2
Cholangiogram 0 1 2
T-Tube 0 1 2
Operative 0 1 2
Transhepatic 0 1 2
Renal Cyst Puncture 0 1 2
Chest Series 0 1 2
Skull Series 0 1 2
Bone Survey 0 1 2
Gallbladder 0 1 2
Hip Series 0 1 2
Esophogram 0 1 2
C-Arm Flouroscope 0 1 2
GI Series 0 1 2
Pediatric Exams 0 1 2
OR Exams 0 1 2
ER Exams 0 1 2
Portable Exams 0 1 2
Foreign Body Localization 0 1 2
Mastoid 0 1 2
Trauma 0 1 2
Facial Series 0 1 2
Salpingogram 0 1 2
GENERAL DIAGNOSTIC (CONT)
Lung Biopsy 0 1 2
ERCP 0 1 2
Tomogram 0 1 2
Arteriograms 0 1 2
Carotid 0 1 2
Pulmonary 0 1 2
Arch 0 1 2
Renal 0 1 2
Femoral 0 1 2
CT SCANNING
Abdomen 0 1 2
Chest 0 1 2
IAC 0 1 2
TM Joints 0 1 2
Spine 0 1 2
Cervical 0 1 2
Lumbar 0 1 2
Thoracic 0 1 2
Biopsy Procedure 0 1 2
Pancreas 0 1 2
Pelvis 0 1 2
Liver 0 1 2
Larnyx 0 1 2
Orbits 0 1 2
Renal Cyst Puncture 0 1 2
Brain/Contrast 0 1 2
Spin-Echo Images 0 1 2
MR Angiography 0 1 2
Mulitplanar Reconstruction 0 1 2
RADIATION THERAPY
Superficial Radiation 0 1 2
Treatment Planning 0 1 2
Linear Accelerator 0 1 2
Cobalt 60 Therapy 0 1 2
Strontium 90 Therapy 0 1 2
Hypothermia Treatment 0 1 2
Dosimetry 0 1 2
NUCLEAR MEDICINE
Cerebral Blood Flow 0 1 2
GI Bleed 0 1 2
Thallium Stress Test 0 1 2
Scans:
Brain 0 1 2
Bone 0 1 2
Gallium 0 1 2
Liver 0 1 2
Lung 0 1 2
Spleen 0 1 2
Thyroid 0 1 2
Renal 0 1 2
MUGA 0 1 2
I-131 Therapy 0 1 2
I-123 Uptake 0 1 2
Radionuclide Arteriogram 0 1 2
Radionuclide Venogram 0 1 2
SPECT Scanning 0 1 2
Thyroid Therapy 0 1 2
MRI TECHNOLOGY
Gradient Echo Imaging 0 1 2
Surface Coils 0 1 2
Weighted Images 0 1 2
T-1 0 1 2
T-2 0 1 2
Spin-Echo Images 0 1 2
Multiplanar Reconstruction 0 1 2
ULTRASOUND
Abdominal
Gallbladder 0 1 2
Liver 0 1 2
Pancreas 0 1 2
Renal 0 1 2
Aorta 0 1 2
Biliary Tract 0 1 2
UGI/Small Bowell 0 1 2
Pelvic 0 1 2
Spleen 0 1 2
Biopsy Puncture 0 1 2
Cyst Aspiration 0 1 2
Vascular
Carotid 0 1 2
Color Flow 0 1 2
Popliteal 0 1 2
Arterial Pressures 0 1 2
Venous Mapping 0 1 2
Venous for DVT 0 1 2
OB/GYN
Ovaries 0 1 2
Uterus 0 1 2
Amniocentesis 0 1 2
Fetal Measurements 0 1 2
Neonatal Head 0 1 2
Transvaginal Probe 0 1 2
Other:
Prostate 0 1 2
Scrotum/Testes 0 1 2
Breast 0 1 2
Thyroid 0 1 2
Transrectal Probe 0 1 2
OPG Eye 0 1 2
Trans-Esophogeal 0 1 2
Trans-Cranial Doppler 0 1 2
ECHOCARDIOGRAPHY
Color Flow 0 1 2
Doppler 0 1 2
M-Mode 0 1 2
Real Time 0 1 2
EQUIPMENT
Toshiba 1.5 0 1 2
Toshiba 1.0 0 1 2
Toshiba .5 0 1 2
Siemens 1.5 0 1 2
Siemens 1.0 0 1 2
Siemens .5 0 1 2
Picker 1.5 0 1 2
Picker 1.0 0 1 2
Picker .5 0 1 2
Phillips 1.5 0 1 2
Phillips 1.0 0 1 2
Phillips .5 0 1 2
Hitachi 1.5 0 1 2
EQUIPMENT (CONT)
Hitachi 1.0 0 1 2
Hitachi .5 0 1 2
GE 1.5 0 1 2
GE 1.0 0 1 2
GE .5 0 1 2
Other equipment: 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(Birth - 1 Year) B= Pediatric/Adolescent(1-18 Yrs) C=Adultt(19-64 Yrs) D=Geriatric(65 + Yrs)
A
B
C
D
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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