[checklist name="CT Tech" mailto="[email protected]" templatedoc="1OUc15TbFrtOHcwpOOBIpJtsYYsEaTa73FBWLy2z9NbY" templatedrive="1LG9WAg21_L3L-ZkZEChBzrYRhBOjpmcc" savedrive="15FFQjDXxe9nC9FkAAcuxbswGy1hq4sWm" sheetid="1xJkggLvktsyYL6zuIhdO-OURJhJTkWdDKunR11agspw"] [checklistHeading title="CT Tech"] Please rate your experience / frequency (within the last year) using the scale (check the appropriate boxes below) 0 = No theory and/or experience 1 = Limited experience/need supervision and/or support 2 = Experienced/minimal support needed to perform) 3 = Proficient/can perform independently 4 = Expert/very experienced in the field [/checklistHeading] [checklistInputGroup name="Recruiter Information"] [checklistInput type="text"]Recruiter TEEMA email[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Personal Information"] [checklistInput type="text"]Full Name[/checklistInput] [checklistInput type="email"]Your Email[/checklistInput] [checklistInput type="text"]Your phone number[/checklistInput] [checklistInput type="text"]Last 4 of Social Security Number[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="CT Technologist Skills"] [checklistInput type="scale"]Abdominal[/checklistInput] [checklistInput type="scale"]Pancreas[/checklistInput] [checklistInput type="scale"]Liver[/checklistInput] [checklistInput type="scale"]Pelvis[/checklistInput] [checklistInput type="scale"]Temporomandibular[/checklistInput] [checklistInput type="scale"]Adrenal[/checklistInput] [checklistInput type="scale"]Aorta[/checklistInput] [checklistInput type="scale"]Thorax[/checklistInput] [checklistInput type="scale"]Brain CT Scans Contrast Non-contrast[/checklistInput] [checklistInput type="scale"]Chest[/checklistInput] [checklistInput type="scale"]Orbit[/checklistInput] [checklistInput type="scale"]Pulmonary embolism[/checklistInput] [checklistInput type="scale"]Internal Auditory canal[/checklistInput] [checklistInput type="scale"]Facial Bone[/checklistInput] [checklistInput type="scale"]Sinus[/checklistInput] [checklistInput type="scale"]Mastoid Scan[/checklistInput] [checklistInput type="scale"]Neck Scans[/checklistInput] [checklistInput type="scale"]Thoracic Scans[/checklistInput] [checklistInput type="scale"]Cervical Spines[/checklistInput] [checklistInput type="scale"]Lumbar/Sacral Spine Scans[/checklistInput] [checklistInput type="scale"]Post Myelogram scans[/checklistInput] [checklistInput type="scale"]Trauma Spinal scans[/checklistInput] [checklistInput type="scale"]Upper extremity scans[/checklistInput] [checklistInput type="scale"]Lower extremity scans[/checklistInput] [checklistInput type="scale"]Renal CT Renal cyst puncture[/checklistInput] [checklistInput type="scale"]Spin-echo images[/checklistInput] [checklistInput type="scale"]Surface coils[/checklistInput] [checklistInput type="scale"]Biopsy procedures[/checklistInput] [checklistInput type="scale"]Gradient Echo imaging[/checklistInput] [checklistInput type="scale"]CT guided Thoracic drainages, abdominal drainages[/checklistInput] [checklistInput type="scale"]Pediatric Head CT Scans[/checklistInput] [checklistInput type="scale"]Pediatric thoracic and abdominal CT Scans[/checklistInput] [checklistInput type="scale"]Quality improvement studies/participation[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Equipment Usage"] [checklistInput type="scale"]General Electric[/checklistInput] [checklistInput type="scale"]Hitachi[/checklistInput] [checklistInput type="scale"]Kodak Processor[/checklistInput] [checklistInput type="scale"]Siemens[/checklistInput] [checklistInput type="scale"]Phillips[/checklistInput] [checklistInput type="scale"]High speed Advantage[/checklistInput] [checklistInput type="scale"]Radiation badge/ PPE[/checklistInput] [checklistInput type="scale"]Hewlett Packard[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Age Specific Competencies"] [checklistInput type="scale"]Infant (Birth - 1 year)[/checklistInput] [checklistInput type="scale"]Preschooler (ages 2-5 years)[/checklistInput] [checklistInput type="scale"]Childhood (ages 6-12 years)[/checklistInput] [checklistInput type="scale"]Adolescents (ages 13-21 years)[/checklistInput] [checklistInput type="scale"]Young Adults (ages 22-39 years)[/checklistInput] [checklistInput type="scale"]Adults (ages 40-64 years)[/checklistInput] [checklistInput type="scale"]Older Adults (ages 65-79 years)[/checklistInput] [checklistInput type="scale"]Elderly (ages 80+ years)[/checklistInput] [/checklistInputGroup] [checklistFooter] [/checklistFooter] [/checklist]