Medical Physicist

Medical Physicist

Name
First Last
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale
No Experience
Theory or observation only during the past 12 months

Limited Experience
Performed less than 12 times within the past 12 months and may need a review

Experienced
Performed at least once per month within the past 12 months and may need minimal assistance

Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient

Procedure

	No Experience	Limited Experience	Experienced	Highly Skilled
Annual audit of radiology
Approval/evaluatino of new procedures
Brachytherapy consultations
Dosimetry and simulation consultations
IMRT
Inservice education of staff
Nuclear medicine QA
Policy and procedures annual review
Quarterly audit of nuclear medicine
Regulatory/radiation safety
Treatment machine QA
Weekly chart checks

Equipment and Software

	No Experience	Limited Experience	Experienced	Highly Skilled
CMS - Focus
CMS - XIO
Elekta - All types
MDS Nordion - Helax
MDS Nordion - Theraplan
Nucletron - Plato
Philips - AcQSim
Philips - P3
Philips - PETPlan
Philips - Pinnacle
Philips - SmartSim
Photoelectron - Intrabeam
Photoelectron - Photon
ROCS - All types
Siemens - IMMaxx
Siemens - KD2
Siemens - Lantis
Siemens - Oncor
Siemens - Primaton
Siemens - Primus
Siemens - Simtec
Varian - Clinac series 2100/2500
Varian - Clinac series 4/1006/100
Varian - Clinac series 600
Varian - Eclipse
Varian - Helios
Varian - Portal vision
Varian - Silhouette
Varian - Varis
Varian - Variseed
Varian - Ximatron
Varian - Trilogy
Tomotherapy
CyberKnife

Age Specific Care

	No Experience	Limited Experience	Experienced	Highly Skilled
Newborn/neonate (Birth-30 days)
Infant (30 days-1 yr)
Toddler (1-3 yrs)
Preschooler (3-5 yrs)
School age children (5-12 yrs)
Adolescents (12-18 yrs)
Young adults (18-39 yrs)
Middle adults (39-64 yrs)
Older adults (64+ yrs)

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