PHYSICS & DOSIMETRY RADIATION SKILLS EVALUATION
PHYSICS & DOSIMETRY RADIATION SKILLS EVALUATION
Personal Information
Name
*
First
Last
Title / Specialty
*
Email
*
Phone
-
(###)
-
###
####
Certifications
ABR
Yes
No
ABPM
Yes
No
CMD
Yes
No
Accelerator
Varian
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Triology
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Tomotherapy
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Seimens
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Elekta
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Nucletron
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Verisource
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Proton
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Model
Additional Accelerators
Treatment Planning
ADAC / Pinnacle
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
CMS / XiO Focus
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
CORVUS / NOMOS
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Plato
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
3D Brachytherapy
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Eclipse
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Rapid ARC
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
ZMED
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Hi-Art System
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Variseed
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Prowess
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Odessy
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Additional Treatment Planning
Record & Verify
VARiS
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
ARIA
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Impac
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
MOSIAQ
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Lantis
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Additional Skills
Brachytherapy
LDR
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Prostate Seed
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
HDR
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Mammosite
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Gliasite
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Prostate
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Broncial
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
GYN
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Additional Brachytherapy
External Beam Treatments
3D Conformal
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
IMRT
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
IGRT
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Gamma Knife
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Cyber Knife
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
X Knife
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Synergy
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
BrainLab
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Novalis / TX
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
IMRT QA
RIT
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Mapcheck
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
Matrix
Very Experienced (can perform well independently)
Exerienced (Need initial review, then can perform independently)
Some Experience (Requires assistance / supervision)
No Experience
