Vascular Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreName(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyDuplex ScansArterial Grafts(Required) 1 2 3 4 Dialysis Grafts(Required) 1 2 3 4 Extracranial Arteries(Required) 1 2 3 4 Lower Extremity Arteries(Required) 1 2 3 4 Carotids(Required) 1 2 3 4 Penile Imaging(Required) 1 2 3 4 Mesenteric Arteries(Required) 1 2 3 4 Upper Extremity Arteries(Required) 1 2 3 4 Renal Arteries / Kidneys(Required) 1 2 3 4 Upper Venous (DVT)(Required) 1 2 3 4 Lower Venous (DVT)(Required) 1 2 3 4 Venous Mapping(Required) 1 2 3 4 Peripherals(Required) 1 2 3 4 Diagnostic AbilitiesAbdominal Aorta / Arteries(Required) 1 2 3 4 Bypass Grafts-Artificial(Required) 1 2 3 4 Bypass Grafts-In Situ(Required) 1 2 3 4 Common Carotid-Extracranial(Required) 1 2 3 4 Dialysis Grafts(Required) 1 2 3 4 Common Carotid-Intracranial(Required) 1 2 3 4 Extremity Arteries-Upper(Required) 1 2 3 4 Extremity Veins-Upper(Required) 1 2 3 4 Extremity Arteries-Lower(Required) 1 2 3 4 Extremity Veins-Lower(Required) 1 2 3 4 Mapping-Arterial(Required) 1 2 3 4 OPG Eye(Required) 1 2 3 4 Mapping-Vein(Required) 1 2 3 4 Penile Exams(Required) 1 2 3 4 Stents(Required) 1 2 3 4 Renal Exams(Required) 1 2 3 4 Indirect TestsContinuous Wave Doppler: Lower Extremity(Required) 1 2 3 4 Continuous Wave Doppler: Upper Extremity(Required) 1 2 3 4 Continuous Wave Doppler: Transcranial(Required) 1 2 3 4 Palmer Arch(Required) 1 2 3 4 Penile(Required) 1 2 3 4 Plethysmography(Required) 1 2 3 4 Pulse Volume Recording(Required) 1 2 3 4 Segmental Pressures-Arterial / Non-Imaging(Required) 1 2 3 4 EquipmentAcuson(Required) 1 2 3 4 Aspen(Required) 1 2 3 4 Cypress(Required) 1 2 3 4 Sequoia(Required) 1 2 3 4 128XP10(Required) 1 2 3 4 Philips / ATL(Required) 1 2 3 4 HDI 1000(Required) 1 2 3 4 HDI 3000(Required) 1 2 3 4 HDI 4000(Required) 1 2 3 4 HDI 5000(Required) 1 2 3 4 UM9 HDI(Required) 1 2 3 4 Philips HP(Required) 1 2 3 4 Sonos 1000(Required) 1 2 3 4 Sonos 2000 / 2500(Required) 1 2 3 4 Sonos 5500(Required) 1 2 3 4 Imagepoint(Required) 1 2 3 4 Imagepoint HX(Required) 1 2 3 4 GE(Required) 1 2 3 4 Logiq 500 PRO(Required) 1 2 3 4 Logiq 7(Required) 1 2 3 4 Logiq 700(Required) 1 2 3 4 Logiq 500MD(Required) 1 2 3 4 Logiq 9(Required) 1 2 3 4 Vivid 7(Required) 1 2 3 4 Vivid 5(Required) 1 2 3 4 Voluson 730(Required) 1 2 3 4 Siemens(Required) 1 2 3 4 Elegra(Required) 1 2 3 4 Prima(Required) 1 2 3 4 Toshiba(Required) 1 2 3 4 SSH-140(Required) 1 2 3 4 PowerVision 8000(Required) 1 2 3 4 Computer SystemsAGFA(Required) 1 2 3 4 Fuji(Required) 1 2 3 4 GE(Required) 1 2 3 4 Siemens(Required) 1 2 3 4 General SkillsPatients in Restraints(Required) 1 2 3 4 Lifting / Transfer Devices(Required) 1 2 3 4 Cardiac Arrest / CPR(Required) 1 2 3 4 Use of Rapid Response Teams(Required) 1 2 3 4 National Patient Safety GoalsAccurate Patient Identification(Required) 1 2 3 4 Effective Communication(Required) 1 2 3 4 Infection Control(Required) 1 2 3 4 Universal Precautions(Required) 1 2 3 4 Patients in Isolation(Required) 1 2 3 4 Minimize Risk for Fall(Required) 1 2 3 4 Age Specific CriteriaNewborn / Neonatal (up to 30 days)(Required) 1 2 3 4 Infant (30 days to 1 year)(Required) 1 2 3 4 Toddler (1 to 3 years)(Required) 1 2 3 4 Preschooler (3 to 5 years)(Required) 1 2 3 4 School Age (5 to 12 years)(Required) 1 2 3 4 Adolescents (12 to 18 years)(Required) 1 2 3 4 Young Adults (18 to 39 years)(Required) 1 2 3 4 Middle Adults (40 to 64 years)(Required) 1 2 3 4 Older Adults (65 & up)(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. 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