Have you graduated from an approved ultrasound/vascular technology education program?
Yes
No
2.
If yes, please specify:
name of program/school:
start of program/school:
date of program completion:
date certificate/degree received:
3.
Have you graduated from a two-year allied health education program that is patient care related?
Yes
No
4.
If yes, please specify:
name of program/school:
start of program/school:
date of program completion:
date certificate/degree received:
type (ie. LVN, RN, EMT, etc.) of certificate/degree received:
5.
Please describe your full-time paid experience(s) performing abdominal ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of abdominal ultrasound procedures you completed in each employment. If you do not have experience in abdominal ultrasound procedures, indicate "none".
6.
Please describe your full-time paid experience(s) performing cardiovascular ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of cardiovascular ultrasound procedures you completed in each employment. If you do not have experience in cardiovascular ultrasound procedures, indicate "none".
7.
Please describe your full-time paid experience(s) performing vascular ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of vascular ultrasound procedures you completed in each employment. If you do not have experience in vascular ultrasound procedures, indicate "none".
8.
Please describe your full-time paid experience(s) performing obstetrical/gynecological ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of obstetrical/gynecological ultrasound procedures you completed in each employment. If you do not have experience in obstetrical/gynecological ultrasound procedures, indicate "none".
9.
Please describe your full-time paid experience(s) performing any other ultrasound procedures/examinations. Indicate job title, employer name, employment dates, and estimated number of each type of ultrasound procedures/examinations you completed in each employment. If you do not have other experience in ultrasound procedures/examinations, indicate "none".
The following list ultrasound procedures typically performed in diagnostic imaging. Please indicate the level of experience and/or training received for following questions.
10.
Indicate your experience level performing abdominal ultrasound procedures in the gallbladderarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
11.
Indicate your experience level performing abdominal ultrasound procedures in the liverarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
12.
Indicate your experience level performing abdominal ultrasound procedures on the renalarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
13.
Indicate your experience level performing abdominal ultrasound procedures on the pancreasarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
14.
Indicate your experience level performing abdominal ultrasound procedures on the aortaarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
15.
Indicate your experience level performing abdominal ultrasound procedures on the spleenarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
16.
Indicate your experience level performing superficial parts ultrasound procedures on the thyroidarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
17.
Indicate your experience level performing superficial parts ultrasound procedures on the testiculararea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
18.
Indicate your experience level performing superficial parts ultrasound procedures on the breastarea.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
19.
Indicate your experience level performing 2nd trimesterobstetric ultrasound procedures.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
20.
Indicate your experience level performing 3rd trimesterobstetric ultrasound procedures.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
21.
Indicate your experience level performing gynecologic: female pelvis (non-pregnant) ultrasound procedures in the transabdominal area.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
22.
Indicate your experience level performing gynecologic: female pelvis (non-pregnant) ultrasound procedures in the endovaginal area.
I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.