Cardiac Echo Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWORK SETTINGSAdult Acute Care(Required) 1 2 3 4 ED/ICU(Required) 1 2 3 4 Adult Outpatient(Required) 1 2 3 4 Pediatric Acute Care(Required) 1 2 3 4 Pediatric Outpatient(Required) 1 2 3 4 ADULT ECHORoutine(Required) 1 2 3 4 3-D Echo(Required) 1 2 3 4 Pedoff Probe(Required) 1 2 3 4 Transesophageal Echo(Required) 1 2 3 4 Stress Echo(Required) 1 2 3 4 Pharmacologic Stress Echo(Required) 1 2 3 4 Post-Cath Echo(Required) 1 2 3 4 Post-Surgical Echo(Required) 1 2 3 4 Imaging with Contrast Agents(Required) 1 2 3 4 Sterilization Procedures(Required) 1 2 3 4 Sterilization ProceduresPulmonary Veins(Required) 1 2 3 4 Hepatic Veins(Required) 1 2 3 4 Suprasternal Notch(Required) 1 2 3 4 CALCULATIONSSimpson's Rule(Required) 1 2 3 4 Proximal Isovelocity Surface Area(Required) 1 2 3 4 Distology with TDI(Required) 1 2 3 4 LV Strain/LV Volume(Required) 1 2 3 4 PEDIATRIC ECHORoutine(Required) 1 2 3 4 3-D Echo(Required) 1 2 3 4 Pedoff Probe(Required) 1 2 3 4 Transesophageal Echo(Required) 1 2 3 4 PEDIATRIC ANOMALIESAortic Arch Abnormalities/Vascular Ring(Required) 1 2 3 4 Arch Sidedness(Required) 1 2 3 4 Coarctation of the Aorta(Required) 1 2 3 4 Coronary Artery Anomalies(Required) 1 2 3 4 Double Outlet Ventricle(Required) 1 2 3 4 Hypoplastic Heart Syndrome(Required) 1 2 3 4 Pulmonary Venous Return Anomalies(Required) 1 2 3 4 Tetralogy of Fallot(Required) 1 2 3 4 Transposition of the Great Vessels(Required) 1 2 3 4 Triscupid and Pulmonary Atresia(Required) 1 2 3 4 Truncus Arteriosis(Required) 1 2 3 4 Univentricular Heart Anomalies(Required) 1 2 3 4 PEDIATRIC POST-SURGICAL SCANSArterial Switch(Required) 1 2 3 4 Blalock - Taussig(Required) 1 2 3 4 Damus-Kaye-Stansel(Required) 1 2 3 4 Fontan(Required) 1 2 3 4 Glenn(Required) 1 2 3 4 Konno(Required) 1 2 3 4 Mustard(Required) 1 2 3 4 Norwood(Required) 1 2 3 4 Rastelli(Required) 1 2 3 4 Sano(Required) 1 2 3 4 Sennig(Required) 1 2 3 4 EQUIPMENTPhillips/ATL(Required) 1 2 3 4 Phillips/ATL (List Types) GE(Required) 1 2 3 4 GE (List Types) Siemens(Required) 1 2 3 4 Siemens (List Types) Toshiba(Required) 1 2 3 4 Toshiba (List Types) Hitachi(Required) 1 2 3 4 Hitachi (List Types) SonoSite(Required) 1 2 3 4 SonoSite (List Types) Other 1 2 3 4 Other: List TECHNOLOGYMcKesson(Required) 1 2 3 4 Epic(Required) 1 2 3 4 Horizon(Required) 1 2 3 4 SCI- Imaging(Required) 1 2 3 4 Online Reporting(Required) 1 2 3 4 EMR Conversion(Required) 1 2 3 4 MISCELLANEOUS12 Lead ECG(Required) 1 2 3 4 Stress Testing(Required) 1 2 3 4 Holter Monitor(Required) 1 2 3 4 PROFESSIONAL KNOWLEDGE AND SKILLSNational Patient Safety Goals(Required) 1 2 3 4 Supervisory /Management Experience(Required) 1 2 3 4 Isolation/Infection Prevention(Required) 1 2 3 4 Procedures for Patients on Ventilators(Required) 1 2 3 4 CERTIFICATIONSRegistered Diagnostic Cardiac Sonograp(Required) Yes No RDCS Expiry DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Registered Cardiac Sonographer (RCS)(Required) Yes No RCS Expiry DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920BLS(Required) Yes No BLS Expiry DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age Specific CompetenciesInfant (Birth - 1 year)(Required) Yes No Preschooler (ages 2-5 years)(Required) Yes No Childhood (ages 6-12 years)(Required) Yes No Adolescents (ages 13-21 years)(Required) Yes No Young Adults (ages 22-39 years)(Required) Yes No Adults (ages 40-64 years)(Required) Yes No Older Adults (ages 65-79 years)(Required) Yes No Elderly (ages 80+ years)(Required) Yes No AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. 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