Radiation Therapy Self Evaluation
Name: ____________________________ ANSWER KEY:
Date: _____________________________ 1 - No Experience 2 - Minimal Experience
SS#: _____________________________ 3 - Moderate Experience 4 - Very Experienced
State License:______ License #________ Exp. Date______ State License:______ License #________ Exp. Date______
Directions: Please indicate your level of experience by placing a check in the box.
Radiation Therapy 1 2 3 4 Provide Therapy to Patients with 1 2 3 4
Treatment Volume Localization GU Cancer
Treatment Prescription Bladder
Geometric Parameters Prostate
Patient Measurements Kidney
Dose Calculation Testicular
Venipuncture
Provide Therapy to Patients with
Teletherapy Gynecologic Cancer
Orthovoltage X-Ray Cervix
Cobalt-60 Endometrium
Linear Accelerator Ovary
Proton Beam Uterus
Neutron Beam Vagina
Stereotactic Radiation Therapy Vulva
Intensity Modulated Radiotherapy
Total Body Irradiation Provide Therapy to Patients with
Head & Neck Cancer
Brachytherapy Larynx
Wires Lip & Oral Cavity
Seeds or Molds Oropharynx
Rods Hypopharynx
Endovascular (Beta-Cath System) Metastatic Squamous
Interstital Brachytheraphy Nasopharynx
Intracavitary Brachytherapy Paranasal Sinus & Nasal Cavity
Intraluminal Radiation Therapy Parathyroid Gland
Intravenous Radioactively Tagged
Molecules Provide Therapy to Patients with
I-131 GI Cancer
Anal
Provide Therapy to Patients with Colon
Bone Cancer Esophagus
Brain & CNS Tumor Rectal
Breast Cancer Gall Bladder
Childhood Cancer Liver
Endocrine System Cancer Pancreas
Hodgkin's Disease
Lymphomas Patient Care
Lung Cancer Explanation of Procedures
Metastatic Cancer Manage Common Emergencies
Penile Cancer Asses Treatment of Side Effects
Soft Tissue Sarcomas Nutrition & Diet Counseling
Vascular Stenosis CDC Isolation Precautions
Disinfection and Cleaning
Handling & Disposal of Hazards
Radiation Therapy Self Evaluation
Equipment Used Model Number Age Specific Criteria 1 2 3 4
GE Newborn/Neonatal (up to 30 days)
Hitachi Infant (30 days to 1 year)
Philips Toddler (1 to 3 years)
Picker Preschooler (3 to 5 years)
Siemens School Age (5 to 12 years)
Toshiba Adolescents (12 to 18 years)
Other Young Adults (18 to 39 years)
Other Middle Adults (40 to 64 years)
Other Older Adults (65 & up)
Facility Setting Years Experience
Small Hospital
Large Hospital
Outpatient
Clinic
Certification / Registries Date
ARRT Expiration Date
MRI Expiration Date
CT Expiration Date
Mammography Expiration Date
Fluoroscopy Expiration Date
NMTCB Expiration Date
ARDMS Expiration Date
Interventional Expiration Date
BCLS Expiration Date
ACLS Expiration Date
Eligible
Other
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