Dosimetrist 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 independentlyAGE OF PATIENTS CARED FORNewborn/Neonate (birth to 30 days)(Required) 1 2 3 4 Infant (1 month to 1 year)(Required) 1 2 3 4 Toddler (1 year to 3 years)(Required) 1 2 3 4 Preschooler (3 years to 5 years)(Required) 1 2 3 4 School Age Child (5 years to 12 years)(Required) 1 2 3 4 Adolescents (12 years to 18 years)(Required) 1 2 3 4 Young Adults (18 years to 39 years)(Required) 1 2 3 4 Middle Adults (39 years to 64 years)(Required) 1 2 3 4 Older Adults (64 years to 79 years)(Required) 1 2 3 4 Elderly Adults (over 79+ years)(Required) 1 2 3 4 GENERAL SKILLSStandard Precautions(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 Pediatric Respiratory/ Cardiac Arrest(Required) 1 2 3 4 Adult Respiratory/ Cardiac Arrest(Required) 1 2 3 4 Crash Carts(Required) 1 2 3 4 Defibrillators(Required) 1 2 3 4 RADIATION THERAPY PHYSICSPhysical Property of Atoms and Nuclei(Required) 1 2 3 4 Basic Nuclear Transformations(Required) 1 2 3 4 Medical Linear Accelerations(Required) 1 2 3 4 Interaction of High Energy Electrons & X-Rays with MatterPhotoelectric Effect(Required) 1 2 3 4 Campton Scatter(Required) 1 2 3 4 Pair Production(Required) 1 2 3 4 Physical Properties of Dose and Exposure(Required) 1 2 3 4 Dosimetry EquipmentIon Chambers(Required) 1 2 3 4 Thermoluminescent Dosimetry(Required) 1 2 3 4 TG-51 (Calibration Protocol)(Required) 1 2 3 4 Radioactive Isotopes(Required) 1 2 3 4 Electron Beam Therapy(Required) 1 2 3 4 IMRT (Intensity Modulated Radiation Therapy)(Required) 1 2 3 4 Beam ModifiersPhysical Wedges(Required) 1 2 3 4 Dynamic Wedges(Required) 1 2 3 4 Blocks(Required) 1 2 3 4 3-D Conformal Radiation Therapy(Required) 1 2 3 4 Basic Principles and ApplicationsCT Scan(Required) 1 2 3 4 MRI Machine(Required) 1 2 3 4 PET Scan(Required) 1 2 3 4 BRACHYTHERAPY PROCEDURESSystemic Errors(Required) 1 2 3 4 Random Errors(Required) 1 2 3 4 Treatment Documentation, Procedure Checklists, & Forms(Required) 1 2 3 4 Application Preparation(Required) 1 2 3 4 Application Insertion(Required) 1 2 3 4 Implant Localization and Stimulation(Required) 1 2 3 4 Treatment Prescription(Required) 1 2 3 4 Implant Design and EvaluationsLocalization(Required) 1 2 3 4 Computer Treatment Planning(Required) 1 2 3 4 Manual Verification of Computer(Required) 1 2 3 4 Patient Preparation, Setup, and Treatment(Required) 1 2 3 4 Post Treatment Quality Assurance(Required) 1 2 3 4 Emergency Procedures for HDRRoutine Emergency Equipment(Required) 1 2 3 4 Physical Plant Emergencies(Required) 1 2 3 4 Minor and Major Emergencies(Required) 1 2 3 4 Intravascular Brachytherapy(Required) 1 2 3 4 Prostate Seed ImplantsI-125 Seeds(Required) 1 2 3 4 P-103 Seeds(Required) 1 2 3 4 Ommaya Reservoir(Required) 1 2 3 4 Ommaya ReservoirAuxiliary Devices (Digitizer, Plotter)(Required) 1 2 3 4 Software(Required) 1 2 3 4 Quality Assurance(Required) 1 2 3 4 SPECIAL TECHNIQUESTBI (Total body Irradiation)(Required) 1 2 3 4 Electron Arc Therapy(Required) 1 2 3 4 Interoperative Electron Therapy(Required) 1 2 3 4 TSI (Total Skin Irradiation)(Required) 1 2 3 4 SRS (Stereotactic Radiosurgery)(Required) 1 2 3 4 Beam Data Acquisition for Small Fields(Required) 1 2 3 4 Treatment Planning Computer Data Input(Required) 1 2 3 4 SRT (Stereotactic Radiotherapy)(Required) 1 2 3 4 STANDARDS FOR TREATMENT PLANS/PROTOCOLSEnsures Accurate Dose(Required) 1 2 3 4 Ensures Proper Patient Positioning(Required) 1 2 3 4 Ensures Proper Machine Settings(Required) 1 2 3 4 Deviation of Normal Parameters for Equipment(Required) 1 2 3 4 Field ShapingCustom Blocking(Required) 1 2 3 4 Multileaf Collimators(Required) 1 2 3 4 Half-Value Thick Blocks(Required) 1 2 3 4 Gonadal Shields(Required) 1 2 3 4 Eye Shields(Required) 1 2 3 4 Internal Shields(Required) 1 2 3 4 In Vivo Dosimetry(Required) 1 2 3 4 TLD (Thermoluminescent Dosimeters) Chips(Required) 1 2 3 4 Patient PositioningImmobilization Devices(Required) 1 2 3 4 Anatomic Landmarks(Required) 1 2 3 4 CertificationsMedical Dosimetrist Certification Board(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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