Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
GENERAL RADIOLOGY
Chest 0 1 2
Abdomen 0 1 2
Facial bones 0 1 2
Skull 0 1 2
Sinuses 0 1 2
Cervical spine 0 1 2
Thoracic spine 0 1 2
Lumbar spine 0 1 2
Hip or Pelvis 0 1 2
Extremities 0 1 2
Shoulder region 0 1 2
IVP 0 1 2
Cholangiograms 0 1 2
Myelogram 0 1 2
Arthrogram 0 1 2
Pediatric Radiology 0 1 2
Portable Radiology 0 1 2
OR Exams 0 1 2
Trauma/ER:
Level I 0 1 2
Level II 0 1 2
Level III 0 1 2
Cardiovascular/Interventional
Cardiac Catheterization 0 1 2
Angioplasty 0 1 2
Artherectomy 0 1 2
Stenting 0 1 2
Thrombolysis
Embolization 0 1 2
Arteriography:
Common carotid 0 1 2
Subclavian/Vertebral 0 1 2
Thoracic aorta 0 1 2
Coronary 0 1 2
Extremity 0 1 2
Abdominal aortography 0 1 2
Mesenteric 0 1 2
Renal 0 1 2
Selective visceral 0 1 2
Pulmonary 0 1 2
Venography 0 1 2
Neprostomy/Urethal stents 0 1 2
CT Studies
Brain/Head 0 1 2
Facial Bones 0 1 2
Chest 0 1 2
CT Assisted biopsy 0 1 2
Neck/Larynx 0 1 2
TM Joints 0 1 2
Cervical spine 0 1 2
Thoracic spine 0 1 2
Lumbar spine 0 1 2
Abdomen:
Routine abdomen 0 1 2
Liver 0 1 2
Pancreas 0 1 2
Renal 0 1 2
GI Tract 0 1 2
Extremities 0 1 2
Sinuses 0 1 2
Orbit 0 1 2
Contrast Agent Preparation 0 1 2
Quality Assurance 0 1 2
Image Display 0 1 2
IAC 0 1 2
MRI TECHNOLOGIST
Head & Neck 0 1 2
Cervical spine 0 1 2
Thoracic spine 0 1 2
Lumbar spine 0 1 2
Abdomen/Pelvis 0 1 2
Extremities 0 1 2
3-D Images 0 1 2
Gradient echo imaging 0 1 2
Multiplanar reconstruction 0 1 2
Functional MRI 0 1 2
Spectroscopy 0 1 2
Use of contrast 0 1 2
Image display & quality 0 1 2
MRI safety procedures 0 1 2
Equipment inspection 0 1 2
MRA 0 1 2
FLUOROSCOPY
Upper GI Series 0 1 2
Small Bowel Series 0 1 2
Barium Enemas 0 1 2
Esophagus 0 1 2
C-Arm Fluoroscopy 0 1 2
Cystograms 0 1 2
Enterolysis 0 1 2
MAMMOGRAPHY
Film Screens 0 1 2
Localizations 0 1 2
Xeromammography 0 1 2
Breast Ultrasound 0 1 2
Ductography 0 1 2
Sterotactic procedure 0 1 2
NUCLEAR MEDICINE
White blood scan 0 1 2
Planar-static 0 1 2
Planar-whole body 0 1 2
SPECT scanning 0 1 2
Three-phase bone scan 0 1 2
Brain scan 0 1 2
Thallium stress test 0 1 2
Thyroid scan 0 1 2
Thyroid uptake 0 1 2
Therapeutic-thyroid 0 1 2
Bone scan 0 1 2
Lymphoscintigraphy 0 1 2
Scintimammography 0 1 2
PET scanning 0 1 2
Three-phase renal scan 0 1 2
VP lungscan 0 1 2
Aerosol lungscan 0 1 2
NUCLEAR MEDICINE (CONT)
Testicular studies 0 1 2
Liver scan 0 1 2
Spleen scan 0 1 2
Schilling’s test 0 1 2
Prostascint 0 1 2
Osteoscan 0 1 2
QC-Radiopharmaceuticals 0 1 2
Gallium Scan 0 1 2
Muga Scan 0 1 2
GI Bleed 0 1 2
Radionuclide arteriogram 0 1 2
Radionuclide venogram 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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