Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
CLINICAL SKILLS
Breast
Tangents Setup Stimulation
S’clav Setup Stimulation
PAB Setup Stimulation
IMC Setup Stimulation
Pelvis
4 field Setup Stimulation
AP/PA Setup Stimulation
6 field conformal Setup Stimulation
Rotational arcs Setup Stimulation
Cranium
R/L Lateral Setup Stimulation
3 field (pituitary) Setup Stimulation
Lung
AP/PA Setup Stimulation
Oblique Setup Stimulation
Head & Neck
3 field Setup Stimulation
R/L Lateral Setup Stimulation
5 field Boost Setup Stimulation
OTHER
CPR No Yes
Oxygen admin No Yes
Dosimetry experience No Yes
Block cutting No Yes
Film processing & QA No Yes
Radiation safety & protection No Yes
Brachytherapy No Yes
MISC
TBI No Yes
Electron set-up No Yes
Skin lesions No Yes
Colorectal No Yes
Esophagus No Yes
Pancreas No Yes
Whole brain No Yes
Spinal cord compressions No Yes
EQUIPMENT
Accelerators No Yes
Record & verify systems No Yes
Treatment planning systems No Yes
Block cutter No Yes

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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