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Payroll Application Medical Inservice Skills Checklists     Sonography Self Evaluation Name: Signature: Date: Click To Highlight: 1 - No Experience 2 - Minimal 3 - Moderate 4 - Very Experienced A. Ultrasound 1   2   3   4   OB/GYN   Transvaginal           Amnio Guidance           OB           OB / BPP           Pelvic         Small Parts   Thyroid           Prostate           Testicular           Neonatal Heads           Breast         Abdominal   Renals           Aorta           Biopsy Guidance           Cyst Aspirations           Pancreas           Liver           Gall Bladder           Spleen           Biliary Tract           Spine         B. Echocardiographer 1   2   3   4   Special Procedures   Bubble Study           Transesophogeal Echocardiogram           Contrast Study           Treadmill Stress Echo           Other         Other Cardiology Testing   Holter Monitors           EKG         Pediatric Echo   2-dimensional           M-mode           PW Doppler           CW Doppler           Color Doppler         Neonatal Echo   2-dimensional           M-mode           PW Doppler           CW Doppler           Color Doppler         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. Vascular     Carotids           Brain & CNS Tumor           Upper Venous (DVT)           Lower Venous (DVT)           Venous Mapping           Upper Arterials           Lower Arterials           Peripherals           Abdominal Doppler         E. Facility Setting Years experience   Small Hospital   Large Hospital   Outpatient   Clinic F. Certification / Registries Date ARRT Expiration Date ARDMS Expiration Date RDCS Expiration Date RVT Expiration Date CCI Expiration Date BCLS Expiration Date ACLS Expiration Date Eligible Other   G. Equipment Y N   Acuson   Aspen               Cypress               Sequoia               128XP10             Philips/ATL   HDI 1000               HDI 3000               HDI 4000               HDI 5000               UM9 HDI             Philips HP   Sonos 1000               Sonos 2000/2500               Sonos 5500               Imagepoint               Imagepoint HX             GE   Logiq 500 PRO               Logiq 7               Logiq 700               Logiq 500MD               Logiq 9               Vivid 7               Vivid 5               Volusion 730             Siemens   Elegra               Prima             Toshiba   SSH-140               Powervision 8000               Other:

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