Radiation Therapy 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 SETTINGHospital(Required) 1 2 3 4 Doctor's Office(Required) 1 2 3 4 Orthopedics(Required) 1 2 3 4 Surgery(Required) 1 2 3 4 Trauma(Required) 1 2 3 4 Other(Required) 1 2 3 4 RADIATION THERAPYOrtho Voltage Radiation Treatment(Required) 1 2 3 4 Simulation of Treatment Sites(Required) 1 2 3 4 Cobalt 60 Therapy(Required) 1 2 3 4 Strontium 90 Therapy(Required) 1 2 3 4 Accelerator with Electrons(Required) 1 2 3 4 Calculations(Required) 1 2 3 4 Radiation Precautions(Required) 1 2 3 4 Hyperthermia Treatment(Required) 1 2 3 4 Linear Accelerator(Required) 1 2 3 4 Superficial Radiation Treatment(Required) 1 2 3 4 Block Cutting(Required) 1 2 3 4 Geometric Parameters(Required) 1 2 3 4 Patient Measurements(Required) 1 2 3 4 Venipuncture(Required) 1 2 3 4 Proton Beam(Required) 1 2 3 4 Neutron Beam(Required) 1 2 3 4 Brachytherapy Wires(Required) 1 2 3 4 Brachytherapy Seeds or Molds(Required) 1 2 3 4 Brachytherapy Rods(Required) 1 2 3 4 Interstitial Brachytherapy(Required) 1 2 3 4 Intraluminal Radiation Therapy(Required) 1 2 3 4 Intravenous Radioactively Tagged Molecules(Required) 1 2 3 4 I-131(Required) 1 2 3 4 PROVISION OF TREATMENTS TO PATIENTS WITHAnal Cancer(Required) 1 2 3 4 Bone Cancer(Required) 1 2 3 4 Brain Cancer(Required) 1 2 3 4 Breast Cancer(Required) 1 2 3 4 Bladder Cancer(Required) 1 2 3 4 Cervical Cancer(Required) 1 2 3 4 Colon Cancer(Required) 1 2 3 4 Esophageal Cancer(Required) 1 2 3 4 Endometrial Cancer(Required) 1 2 3 4 Gallbladder Cancer(Required) 1 2 3 4 Hodgkin’s and Other Lymphomas(Required) 1 2 3 4 Hypopharyngeal Cancer(Required) 1 2 3 4 Kidney Cancer(Required) 1 2 3 4 Laryngeal Cancer(Required) 1 2 3 4 Lip and Oral Cavity Cancer(Required) 1 2 3 4 Lung Cancer(Required) 1 2 3 4 Liver Cancer(Required) 1 2 3 4 Metastatic Squamous Cancer(Required) 1 2 3 4 Ovarian Cancer(Required) 1 2 3 4 Oropharyngeal Cancer(Required) 1 2 3 4 Penile Cancer(Required) 1 2 3 4 Pancreatic Cancer(Required) 1 2 3 4 Testicular Cancer(Required) 1 2 3 4 Uterine Cancer(Required) 1 2 3 4 Vaginal Cancer(Required) 1 2 3 4 Vulvular Cancer(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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