Ultrasound 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 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)(Required) 1 2 3 4 GENERAL SKILLSPreparation of Examination Room(Required) 1 2 3 4 Identification of Patient(Required) 1 2 3 4 Patient Assessment & Education Regarding Procedure(Required) 1 2 3 4 Patient Positioning(Required) 1 2 3 4 Protocol Selection(Required) 1 2 3 4 Image Archiving(Required) 1 2 3 4 Documentation of Procedure and Patient Data(Required) 1 2 3 4 CDC Standard Precautions(Required) 1 2 3 4 Correlation of Adjunct Imaging Studies to Breast Sonogram(Required) 1 2 3 4 Doppler Mode Selection(Required) 1 2 3 4 Abdomen/ PelvisLiver(Required) 1 2 3 4 Biliary Tract/ Gallbladder / CBD(Required) 1 2 3 4 Pancreas(Required) 1 2 3 4 Spleen(Required) 1 2 3 4 Kidneys(Required) 1 2 3 4 Adrenals(Required) 1 2 3 4 Bladder(Required) 1 2 3 4 Lymph Nodes(Required) 1 2 3 4 Aorta/ Great Vessels(Required) 1 2 3 4 Vasculature(Required) 1 2 3 4 SUPERFICIAL STRUCTURES STUDIESAbdominal wall(Required) 1 2 3 4 Scrotum & Testis(Required) 1 2 3 4 Abdominal wall(Required) 1 2 3 4 Musculoskeletal(Required) 1 2 3 4 Superficial masses(Required) 1 2 3 4 Thyroid(Required) 1 2 3 4 GYNECOLOGICAL STUDIESUterus(Required) 1 2 3 4 Adnexa(Required) 1 2 3 4 Transvaginal Probe(Required) 1 2 3 4 Transvaginal Probe1st Trimester(Required) 1 2 3 4 2nd / 3rd Trimester(Required) 1 2 3 4 Fetal Biophysical Profile(Required) 1 2 3 4 Amniocentesis(Required) 1 2 3 4 Interventional ProceduresBiopsy(Required) 1 2 3 4 Aspiration(Required) 1 2 3 4 Drainage Procedures(Required) 1 2 3 4 Thoracentesis(Required) 1 2 3 4 Paracentesis(Required) 1 2 3 4 Sterile Techniques(Required) 1 2 3 4 Pediatric Studies(Required) 1 2 3 4 Abdomen/ PelvisArterial - Aorta(Required) 1 2 3 4 Arterial/Venous - Superior Mesenteric(Required) 1 2 3 4 Arterial/Venous - Inferior Mesenteric(Required) 1 2 3 4 Arterial - Celiac(Required) 1 2 3 4 Arterial / Venous - Hepatic(Required) 1 2 3 4 Arterial / Venous - Common Iliac(Required) 1 2 3 4 Arterial / Venous - Internal Iliac(Required) 1 2 3 4 Arterial / Venous - External Iliac(Required) 1 2 3 4 Arterial / Venous - Renal(Required) 1 2 3 4 Arterial / Venous - Splenic(Required) 1 2 3 4 Venous - Inferior Vena Cava(Required) 1 2 3 4 Venous - Portal(Required) 1 2 3 4 Transplants - Liver(Required) 1 2 3 4 Transplants - Renal(Required) 1 2 3 4 Upper ExtremitySubclavian(Required) 1 2 3 4 Axillary(Required) 1 2 3 4 Brachial(Required) 1 2 3 4 Radial(Required) 1 2 3 4 Ulnar(Required) 1 2 3 4 Digital(Required) 1 2 3 4 Lower ExtremityCommon Femoral(Required) 1 2 3 4 Superficial Femoral(Required) 1 2 3 4 Deep Femoral(Required) 1 2 3 4 Popliteal(Required) 1 2 3 4 Tibioperoneal Trunk(Required) 1 2 3 4 Posterior Tibial or Anterior Tibial or Peroneal(Required) 1 2 3 4 Stress/ Pressure TestingSegmental Pressure-Upper Extremities(Required) 1 2 3 4 ABI or Segmental Pressure-Lower Ext(Required) 1 2 3 4 PVR (Pulse Volume Recording)(Required) 1 2 3 4 Digital Pressure(Required) 1 2 3 4 Post-Exercise Testing(Required) 1 2 3 4 Upper Extremity VenousInternal Jugular(Required) 1 2 3 4 Subclavian(Required) 1 2 3 4 Axillary(Required) 1 2 3 4 Brachial(Required) 1 2 3 4 Cephalic(Required) 1 2 3 4 Basilic(Required) 1 2 3 4 Radial(Required) 1 2 3 4 Ulnar(Required) 1 2 3 4 Vein Mapping(Required) 1 2 3 4 Lower Extremity VenousCommon Femoral(Required) 1 2 3 4 Femoral(Required) 1 2 3 4 Deep Femoral(Required) 1 2 3 4 Popliteal(Required) 1 2 3 4 Great Saphenous(Required) 1 2 3 4 Small Saphenous(Required) 1 2 3 4 Calf Veins(Required) 1 2 3 4 Vein Mapping(Required) 1 2 3 4 Reflux Assessment(Required) 1 2 3 4 NECKCarotid Artery(Required) 1 2 3 4 Vertebral Artery(Required) 1 2 3 4 Subclavian Artery(Required) 1 2 3 4 POST INTERVENTION PROCEDURESBypass Grafts(Required) 1 2 3 4 Post Catheterization Complications(Required) 1 2 3 4 Endografts(Required) 1 2 3 4 Dialysis Access Grafts/ Fistulae(Required) 1 2 3 4 Stents(Required) 1 2 3 4 Angioplasty(Required) 1 2 3 4 TIPS(Required) 1 2 3 4 BREAST SONOGRAPHYFluid Aspiration(Required) 1 2 3 4 Fine Needle Aspiration(Required) 1 2 3 4 Core Biopsy(Required) 1 2 3 4 Vacuum - Assisted Biopsy(Required) 1 2 3 4 Clip Placement(Required) 1 2 3 4 Needle Localization(Required) 1 2 3 4 EMReClinicalworks(Required) 1 2 3 4 EPIC(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Care 360(Required) 1 2 3 4 Allscripts(Required) 1 2 3 4 Cerner(Required) 1 2 3 4 GE(Required) 1 2 3 4 Optum Insight(Required) 1 2 3 4 NextGen(Required) 1 2 3 4 Greenway(Required) 1 2 3 4 PACSAmbra Health(Required) 1 2 3 4 Sectra(Required) 1 2 3 4 Infinitt(Required) 1 2 3 4 IBM Merge(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Philips(Required) 1 2 3 4 FujiFilm(Required) 1 2 3 4 Impax(Required) 1 2 3 4 Centricity(Required) 1 2 3 4 Carestream Vue(Required) 1 2 3 4 Clarity(Required) 1 2 3 4 eRad PACS(Required) 1 2 3 4 Syngo(Required) 1 2 3 4 EQUIPMENTSAcuson(Required) 1 2 3 4 Aspen(Required) 1 2 3 4 Cypress(Required) 1 2 3 4 Sequoia(Required) 1 2 3 4 128XP10(Required) 1 2 3 4 Philips/ ATL(Required) 1 2 3 4 HDI 1000(Required) 1 2 3 4 HDI 3000(Required) 1 2 3 4 HDI 4000(Required) 1 2 3 4 HDI 5000(Required) 1 2 3 4 UM9 HDI(Required) 1 2 3 4 Philips P(Required) 1 2 3 4 Sonos 1000(Required) 1 2 3 4 Sonos 2000/ 2500(Required) 1 2 3 4 Sonos 5500(Required) 1 2 3 4 Imagepoint(Required) 1 2 3 4 Imagepoint HX(Required) 1 2 3 4 GE(Required) 1 2 3 4 Logiq 500 PRO(Required) 1 2 3 4 Logiq 7(Required) 1 2 3 4 Logiq 700(Required) 1 2 3 4 Logiq 500MD(Required) 1 2 3 4 Logiq 9(Required) 1 2 3 4 Vivid 5(Required) 1 2 3 4 Vivid 7(Required) 1 2 3 4 Volusion 730(Required) 1 2 3 4 Siemens(Required) 1 2 3 4 Elegra(Required) 1 2 3 4 Prima(Required) 1 2 3 4 Toshiba(Required) 1 2 3 4 SSH-140(Required) 1 2 3 4 Powervision 8000(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. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.CAPTCHANameThis field is for validation purposes and should be left unchanged.
