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Payroll Application Medical Inservice Skills Checklists     Radiation therapy Name: Verify ID: Date: Click To Highlight: 1 - No Experience 2 - Minimal 3 - Moderate 4 - Very Experienced A. Radiation Therapy 1   2   3   4     Treatment Volume Localization           Treatment Prescription           Geometric Parameters           Patient Measurements           Dose Calculation           Venipuncture         B. Teletherapy     Orthovoltage X-Ray           Cobalt-60           Linear Accelerator           Proton Beam           Neutron Beam           Stereotactic Radiation Therapy           Intensity Modulated Radiotherapy           Total Body Irradiation         C. Brachytherapy     Wires           Seeds or Molds           Rods           Endovascular (Beta-Cath System)           Interstital Brachytheraphy           Intracavitary Brachytherapy           Intraluminal Radiation Therapy           Intravenous Radioactively Tagged Molecule           I-131         D. Provide Therapy to Patients with     Bone Cancer           Brain & CNS Tumor           Breast Cancer           Childhood Cancer           Endocrine System Cancer           Hodgkin´s Disease           Lymphomas           Lung Cancer           Metastatic Cancer           Penile Cancer           Soft Tissue Sarcomas           Vascular Stenosis         E. Equipment Used Model Number   GE   Hitachi   Philips   Picker   Siemens   Toshiba   Other   Other   Other F. Certification ⁄ Registries Date A. ARRT Expiration Date   a. MRI Expiration Date   b. CT Expiration Date   c. Mammography Expiration Date   d. Fluoroscopy Expiration Date   NMTCB Expiration Date   ARDMS Expiration Date   Interventional Expiration Date   BCLS Expiration Date   ACLS Expiration Date   Eligible     Other     G. Provide Therapy to Patients with GU Cancer 1   2   3   4     Bladder           Prostate           Kidney           Testicular         H. Provide Therapy to Patients with Gynecologic Cancer     Cervix           Endometrium           Ovary           Uterus           Vagina           Vulva         I. Provide Therapy to Patients with Head & Neck Cancer     Larynx           Lip & Oral Cavity           Oropharynx           Hypopharynx           Metastatic Squamous           Nasopharynx           Paranasal Sinus & Nasal Cavity           Parathyroid Gland         J. Provide Therapy to Patients with GI Cancer     Anal           Colon           Esophagus           Rectal           Gall Bladder           Liver           Pancreas           Parathyroid Gland         K. Patient Care     Explanation of Procedures           Manage Common Emergencies           Asses Treatment of Side Effects           Nutrition & Diet Counseling           CDC Isolation Precautions           Disinfection and Cleaning           Handling & Disposal of Hazards         L. 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)

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