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Radiation Therapist
Radiation Therapist
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
Record and Verify Systems
No Experience
Limited Experience
Experienced
Highly Skilled
Impac
MOSAIQ
Lantis
Varis
ARIA
Portal vision
Treatment Units
No Experience
Limited Experience
Experienced
Highly Skilled
GE Saturn
Mitsubishi EXL
Philips Elekta Sli
Philips Elekta Sli 15
Philips Elekta SL 18
Philips Elekta SL 755
Elekta Synergy
Siemens PRIMUS
Siemens PRIMATRON
Siemens KD and KD2
Siemens MD and MD2
Siemens Mevatron 77
Varian Clinac 6 EX
Varian Clinac 21 EX
Varian Clinac 23 EX
Varian Clinac 600
Varian Clinac 600 C/D
Varian Clinac 2100 C/D
Varian Clinac 2100 w/ MLC
Varian Clinac 2300 C/D
Varian 6/100
Varian 1800 C
Varian 4 MeV
Varian 6 MeV
Varian 18 MeV
Varian 20 MeV
Varian 35 MeV
Varian Trilogy
TomoTherapy
Procedures
No Experience
Limited Experience
Experienced
Highly Skilled
Block cutting
Huestis block cutting
Custom molds
IMRT
Simulations
Stereotactic radiotherapy
Superficial orthovoltage
Treatment planning
MLC
Clinical setups
Bat systems
Brachy therapy
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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