Personal Information

*Please fill the email ID correctly for successful submission

Proﬁciency Scale:

1 – No experience; Theory/observed only

2 – Limited competency; < 5 times per year; Needs supervision

3 – Acceptable competency; > 5 times per year

4 – Competent; Performs on a daily or weekly basis; Proficient

Please list any additional areas of expertise below:

I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Proﬁciency Scale:

Ultrasound – Echocardiography

Pediatric Echo

Equipment

Age Specific Practice Criteria

EMR