Nuclear Medicine Technologist Skills Checklist

Congratulations on your decision to apply with Eminent Medical Staffing! Before we can offer candidates allied health employment, a skills assessment must be performed. Please complete this form completely and as accurately as possible. Thank you and we look forward to working with you!

Caregiver completing this form*

First NameLast Name

Date*

MonthDayYear

Phone Number*

Area CodePhone Number

E-mail*

Confirmation Email

Please enter the last 4 of your social security #*

Do you hold a valid social security card?*

YesNo

Please mark your level of experience

1. No theory and/or experience
2. Limited experience/need supervision and/or support
3. Experienced/minimal support needed to perform
4. Proficient/can perform independently

How Many Years of Experience do you Have?*

What is the name of your recruiter with Eminent Medical Staffing?*

If you do not know please type "unassigned"

WORK SETTINGS*

	No Experience	Limited Experience	Experienced	Proficient
Adult Acute Care
Adult Outpatient
Pediatric Inpatient/Outpatient
Bedside/Portable Procedures
Charge/Lead Experience
Nuclear Cardiology

Please list Nuc Med Imaging Systems you have worked with and select your proficiency. Click + to add more

PROCEDURES *

	No Experience	Limited Experience	Experienced	Proficient
Arteriogram/Radionuclide
Abscess Localization Whole Body
Abscess Localization Individual Sites
CCK/Ejection Fraction
Cisternogram
CSF Leak Localization
Gallium Scan
Gastric Emptying
GI Bleed
HIDA Scan
Indium 111 WBC Scan Whole Body
Indium 111 WBC Scan Limited
Injection-Lymphatic
Lymphatic Scan-Melanoma
Meckels Scan
Morphine Augmentation
MUGA Scan
Radiopharmaceutical Prep
Radionuclide Arteriogram
Renagram
Parathyroid
Salivary Glands
Ventricular Shunt
Zevalin Treatment
Hyperthyroid Treatment
I 131 Therapy Thyroid Ablation
Therapy Pain

Bone Scan*

	No Experience	Limited Experience	Experienced	Proficient
Whole Body
3 Phase
Limited

Brain Scan*

	No Experience	Limited Experience	Experienced	Proficient
Cerebral Blood Flow

Liver/Spleen Scan*

	No Experience	Limited Experience	Experienced	Proficient
Liver/Spleen Scan
Liver Scan-Hemangioma
Liver Imaging
Liver Flow

Lung Scan*

	No Experience	Limited Experience	Experienced	Proficient
DTPA Aerosol
Perfusion
Ventilation/Perfusion

Renal Flow*

	No Experience	Limited Experience	Experienced	Proficient
With Lasix
Flow/Function
Three Phase
Captopril

Shunt*

	No Experience	Limited Experience	Experienced	Proficient
Abdominal
Ventricular

Thyroid Studies*

	No Experience	Limited Experience	Experienced	Proficient
Cancer Survey
Uptake Scan
I 123 Scan

Tumor Localization*

	No Experience	Limited Experience	Experienced	Proficient
Whole Body
Limited

NM Spect*

	No Experience	Limited Experience	Experienced	Proficient
Bone
Brain
Liver
Liver Spect w/Flow
Renal

Myocardial*

	No Experience	Limited Experience	Experienced	Proficient
Infarction
Exercise/Rest-Single
Exercise/Rest-Multiple
Pharmacological Stress
Thallium/Persantine

PROFESSIONAL KNOWLEDGE AND SKILLS*

	No Experience	Limited Experience	Experienced	Proficient
Quality Control Equipment
Daily Surveys/Wipe Testing
Hot Lab Management Dose Calibrators
Hot Lab Management Generators
Computerized Charting
National Patient Safety Goals
Universal Protocol Procedures/Core Measures
Isolation Precautions
Infection Prevention
Age Specific/Population-Based Care
Fall Risk Assessment/Prevention

EMR Conversion

YESNo

BLS

ARRT (R)

ARRT (N)

CNMT

NMTCB

NCT

Certified PET Technologist

Veinipuncture

Fluoroscopy

List state licenses:

Please read and agree to the statements below by marking the checkbox.

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a Healthcare Professional with those facilities.*

Yes, I agree

Signature*

Nuclear Medicine Technologist Skills Checklist

CT Imaging Systems

CERTIFICATIONS / LICENSURE / REGISTRATIONS