Radiology Tech Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlySettingAdult Inpatient 1 2 3 4 ER/Trauma 1 2 3 4 Adult Outpatient 1 2 3 4 Pediatric Inpatient 1 2 3 4 Pediatric Outpatient 1 2 3 4 ExtremitiesChest Studies 1 2 3 4 Abdominal Studies 1 2 3 4 Foreign Body/Soft Tissue Studies 1 2 3 4 Specimen Radiography 1 2 3 4 ProceduresUpper 1 2 3 4 Lower 1 2 3 4 Pelvis Obls/Judet Views 1 2 3 4 Pelvis SI Joints 1 2 3 4 Pelvis Sacrum/Coccyx 1 2 3 4 SpineCervical Spine-Obls/Flexion/Extension 1 2 3 4 Thoracic Spine-Swimmer’s View 1 2 3 4 Lumbar Spine-Obls/Flexion. Extension 1 2 3 4 HeadFacial Bones 1 2 3 4 Mandible 1 2 3 4 Mastoids 1 2 3 4 Orbits 1 2 3 4 Sinus Series 1 2 3 4 TMJ 1 2 3 4 Skull Series 1 2 3 4 TomographyRenal 1 2 3 4 TMJ 1 2 3 4 Spine 1 2 3 4 Flouroscopy/Contrast StudiesBarium Swallow/Esophagram 1 2 3 4 Modified Barium Swallow/Protocol Swallow 1 2 3 4 Swallow Studies with Videotaping 1 2 3 4 Upper GI Series-Single Contrast 1 2 3 4 Upper GI Series-Air Contrast 1 2 3 4 Small Bowel Follow Through 1 2 3 4 Enema StudiesBarium Enema-Single Contrast 1 2 3 4 Water Soluble Contrast Enema (e.g. Hypaque) 1 2 3 4 Barium Enema-Air Contrast 1 2 3 4 Lower GI Studies thru Colostomy 1 2 3 4 CystographyCystogram 1 2 3 4 Voiding Cystogram 1 2 3 4 Urethrography 1 2 3 4 Contrast Injection StudiesIVP 1 2 3 4 IVP with Tomograms 1 2 3 4 MyelogramsCervical Spine 1 2 3 4 Thoracic Spine 1 2 3 4 Lumbar Spine 1 2 3 4 Mobile C-Arm FlouroscopyBroncoscopy with Fluoro Guidance 1 2 3 4 Bedside Line and Tube Placement 1 2 3 4 OR CasesSterile Procedures in OR 1 2 3 4 Spine Work 1 2 3 4 Operative Cholangiography 1 2 3 4 Hip Studies 1 2 3 4 Extremity Studies 1 2 3 4 Cystography 1 2 3 4 Retrograde Urography 1 2 3 4 Patient SafetyNational Patient Safety Goals 1 2 3 4 Computerized Charting 1 2 3 4 Age Specific CompetenciesNewborn/neonate (Birth - 30 days) 1 2 3 4 Infant (30 days - 1 year) 1 2 3 4 Toddler (1-3 years) 1 2 3 4 Preschooler (ages 3-5 years) 1 2 3 4 School age (ages 5-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Radiology Tech Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
