Nuclear Medicine Technologist Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyProceduresArteriogram/Radionuclide(Required) 1 2 3 4 Abscess Localization Whole Body(Required) 1 2 3 4 Abscess Localization Individual Sites(Required) 1 2 3 4 CCK/Ejection Fraction(Required) 1 2 3 4 Cisternogram(Required) 1 2 3 4 CSF Leak Localization(Required) 1 2 3 4 Gallium Scan(Required) 1 2 3 4 Gastric Emptying(Required) 1 2 3 4 GI Bleed(Required) 1 2 3 4 HIDA Scan(Required) 1 2 3 4 Indium 111 WBC Scan Whole Body(Required) 1 2 3 4 Indium 111 WBC Scan Limited(Required) 1 2 3 4 Injection-Lymphatic(Required) 1 2 3 4 Lymphatic Scan-Melanoma(Required) 1 2 3 4 Meckels Scan(Required) 1 2 3 4 Morphine Augmentation(Required) 1 2 3 4 MUGA Scan(Required) 1 2 3 4 Radiopharmaceutical Prep(Required) 1 2 3 4 Radionuclide Arteriogram(Required) 1 2 3 4 Renagram(Required) 1 2 3 4 Parathyroid(Required) 1 2 3 4 Salivary Glands(Required) 1 2 3 4 Ventricular Shunt(Required) 1 2 3 4 Zevalin Treatment(Required) 1 2 3 4 Hyperthyroid Treatment(Required) 1 2 3 4 I 131 Therapy Thyroid Ablation(Required) 1 2 3 4 Therapy Pain(Required) 1 2 3 4 Bone ScanWhole Body(Required) 1 2 3 4 3 Phase(Required) 1 2 3 4 Limited(Required) 1 2 3 4 Brain ScanCerebral Blood Flow(Required) 1 2 3 4 Liver/Spleen ScanLiver/Spleen Scan(Required) 1 2 3 4 Liver Scan-Hemangioma(Required) 1 2 3 4 Liver Imaging(Required) 1 2 3 4 Liver Flow(Required) 1 2 3 4 Lung ScanDTPA Aerosol(Required) 1 2 3 4 Perfusion(Required) 1 2 3 4 Ventilation/Perfusion(Required) 1 2 3 4 Renal FlowWith Lasix(Required) 1 2 3 4 Flow/Function(Required) 1 2 3 4 Three Phase(Required) 1 2 3 4 Captopril(Required) 1 2 3 4 ShuntAbdominal(Required) 1 2 3 4 Ventricular(Required) 1 2 3 4 Thyroid StudiesCancer Survey(Required) 1 2 3 4 Uptake Scan(Required) 1 2 3 4 I 123 Scan(Required) 1 2 3 4 AuthorizationsWhole Body(Required) 1 2 3 4 Limited(Required) 1 2 3 4 NM SpectBone(Required) 1 2 3 4 Brain(Required) 1 2 3 4 Liver(Required) 1 2 3 4 Liver Spect w/Flow(Required) 1 2 3 4 Renal(Required) 1 2 3 4 MyocardialInfarction(Required) 1 2 3 4 Exercise/Rest-Single(Required) 1 2 3 4 Exercise/Rest-Multiple(Required) 1 2 3 4 Pharmacological Stress(Required) 1 2 3 4 Thallium/Persantine(Required) 1 2 3 4 Professional Knowledge and SkillsQuality Control Equipment(Required) 1 2 3 4 Daily Surveys/Wipe Testing(Required) 1 2 3 4 Hot Lab Management Dose Calibrators(Required) 1 2 3 4 Hot Lab Management Generators(Required) 1 2 3 4 Computerized Charting(Required) 1 2 3 4 National Patient Safety Goals(Required) 1 2 3 4 Universal Protocol Procedures/Core Measures(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 Age Specific/Population-Based Care(Required) 1 2 3 4 Fall Risk Assessment/Prevention(Required) 1 2 3 4 Age SpecificAge Specific(Required) 1 2 3 4 Adolescents (12 to 18 years)(Required) 1 2 3 4 Young Adults (18 to 39 years)(Required) 1 2 3 4 Middle Adults (40 to 64 years)(Required) 1 2 3 4 Older Adults (65 & up)(Required) 1 2 3 4 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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