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.
| AGE OF PATIENTS CARED FOR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Newborn/Neonate (birth to 30 days) |
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| Infant (1 month to 1 year) |
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| Toddler (1 year to 3 years) |
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| Preschooler (3 years to 5 years) |
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| School Age Child (5 years to 12 years) |
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| Adolescents (12 years to 18 years) |
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| Young Adults (18 years to 39 years) |
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| Middle Adults (39 years to 64 years) |
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| Older Adults (64 years to 79 years) |
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| Elderly Adults (over 79+ years) |
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| GENERAL SKILLS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Standard Precautions |
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| Isolation Precautions |
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| Pediatric Respiratory/ Cardiac Arrest |
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| Adult Respiratory/ Cardiac Arrest |
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| Crash Carts |
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| Defibrillators |
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| RADIATION THERAPY PHYSICS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Physical Property of Atoms and Nuclei |
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| Basic Nuclear Transformations |
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| Medical Linear Accelerations |
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| Interaction of High Energy Electrons & X-Rays with Matter | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Photoelectric Effect |
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| Campton Scatter |
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| Pair Production |
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| Physical Properties of Dose and Exposure |
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| Dosimetry Equipment | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Ion Chambers |
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| Thermoluminescent Dosimetry |
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| TG-51 (Calibration Protocol) |
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| Radioactive Isotopes |
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| Electron Beam Therapy |
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| IMRT (Intensity Modulated Radiation Therapy) |
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| Beam Modifiers | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Physical Wedges |
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| Dynamic Wedges |
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| Blocks |
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| 3-D Conformal Radiation Therapy |
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| Basic Principles and Applications | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| CT Scan |
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| MRI Machine |
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| PET Scan |
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| BRACHYTHERAPY PROCEDURES | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Systemic Errors |
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| Random Errors |
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| Treatment Documentation, Procedure Checklists, & Forms |
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| Application Preparation |
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| Application Insertion |
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| Implant Localization and Stimulation |
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| Treatment Prescription |
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| Implant Design and Evaluations | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Localization |
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| Computer Treatment Planning |
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| Manual Verification of Computer |
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| Patient Preparation, Setup, and Treatment |
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| Post Treatment Quality Assurance |
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| Emergency Procedures for HDR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Routine Emergency Equipment |
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| Physical Plant Emergencies |
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| Minor and Major Emergencies |
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| Intravascular Brachytherapy |
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| Prostate Seed Implants: | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| I-125 Seeds |
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| P-103 Seeds |
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| Ommaya Reservoir |
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| TREATMENT PLANNING | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Auxiliary Devices (Digitizer, Plotter) |
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| Software |
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| Quality Assurance |
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| SPECIAL TECHNIQUES | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| TBI (Total body Irradiation) |
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| Electron Arc Therapy |
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| Interoperative Electron Therapy |
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| TSI (Total Skin Irradiation) |
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| SRS (Stereotactic Radiosurgery) |
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| Beam Data Acquisition for Small Fields |
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| Treatment Planning Computer Data Input |
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| SRT (Stereotactic Radiotherapy) |
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| STANDARDS FOR TREATMENT PLANS/PROTOCOLS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Ensures Accurate Dose |
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| Ensures Proper Patient Positioning |
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| Ensures Proper Machine Settings |
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| Deviation of Normal Parameters for Equipment |
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| Field Shaping | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Custom Blocking |
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| Multileaf Collimators |
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| Half-Value Thick Blocks |
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| Gonadal Shields |
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| Eye Shields |
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| Internal Shields |
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| In Vivo Dosimetry |
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| TLD (Thermoluminescent Dosimeters) Chips |
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| Patient Positioning | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Immobilization Devices |
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| Anatomic Landmarks |
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| Certifications | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Medical Dosimetrist Certification Board |
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