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Payroll Application Medical Inservice Skills Checklists     Nuclear medicine Name: Verify ID: Date: Click To Highlight: 1 - No Experience 2 - Minimal 3 - Moderate 4 - Very Experienced A. Nuclear Medicine 1   2   3   4     NVG Stress           Stress Holter Monitoring           NVG Rest           Indium I-11 WBC           Cardiolite Stress ⁄ Rest           Radio Pharmacutical Prep           Radionuclide Arteriograms           Persantine Thallium           Radionuclide Venegrams           Testicular Studies           Aerosal Lung Scan           Liver Scan           Muga Scan           Spleen Scan           I-123 Uptake           I-131 Therapy           Brachytherapy           Bone Scan           Brain Scan           Cerebral Blood Flow           HIDA Scan           Shilihgs           Renagram           Renal Scan           Gallium Scan           Hot Lab           Thallium Stress Test           Thyroid Uptake           Thoracentesis           Thyroid Therapy           Thyroid Scan           GI Bleeding Studies           Radio Immuno Assay           VP Lung Scan           Spect Scan         B. Certification ⁄ Registries Date   ARRT Expiration Date   NMTCB Expiration Date   BCLS Expiration Date   ACLS Expiration Date   Eligible   Other C. Age Specific Criteria     Newborn/Neonatal (up to 30 days)           Infant (30 days to 1 year)           Toddler (1 to 3 years)           Preschooler (3 to 5 years)           School Age (5 to 12 years)           Adolescents (12 to 18 years)           Young Adults (18 to 39 years)           Middle Adults (40 to 64 years)           Older Adults (65 & up)           D. Equipment 1   2   3   4     3-D Reconstruction Packet           ADAC Camera           ADAC Computer           Centiview           Digital Computer           Elscint Camera           GE LFOV           GE MAXI 400 Camera           GE Star 1 Computer           GE Star Cam Computer           GE Star Cam Spect           Genesis           Genesis Computer           Hepatic Hernangloma           Hitachi           MDS Camera (Medisept)           MDS Computer (Medisept)           Micro Dot Computer           Ohio Nuclear           Ohio Nuclear 410 Camera           Omega 500           Omega 500 Computer           Phillips (NM)           PhoGamma IV           Picker (NM)           Picker Prism           Siemens Computer           Siemens Diacam           Siemens Orbiter Camera           Siemens Spect           Sophy Computer           Summit           Technicare 438 Camera           Technicare Omega 500 Camera           Techincare 560 Computer           Technicare Port 420 ⁄ 550           Toshiba 6000           Other         E. Facility Setting Years Experience   Small Hospital   Large Hospital   Outpatient   Clinic

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