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University of Wisconsin---La Crosse

Medical Dosimetry Program

Competency Check list

Student Name: K1 IL 6a rA -4-70

Clinical Site: be i rio C Ca a ce Ce-ri 144- Wa ire v I Ile Can ce Cetrie-
Competency Date Typhon
Performed Evaluation

Palliative (Spine, Hip, Ribs, etc) 3/ZS 9/(

Para-aortic or nodal irradiation 1 if s I al'
3 /25--
Limb Sarcoma 1-119 -III
Pelvis - GYN
Intact Breast Tangents
2/a S
0Or Who
Chest Wall Tangents (bolus: non-bolus weighting) with
s'Clay awl PAB
ell cpi,iti
ReTreat avoiding or matching old port (any area) "7 /22_ 94./ 21 s"
Lung with Boost (conformal) 7/1% eCinC
Abdominal IMRT (e.g. Pancreas) I 1S t412 1716
l3rain IMRT with MR fusion 1213 4 16 k

Prostate IMRT 10/2S" 0 1-2-16

Prostate with nodes (IMRT) WI 019
H & N IMRT I ///4 . i'2(,
Thoracic IMRT (e.g. Esophagus or Lung) i2-/9

Electron Beam Plan 3/Z2 rfe Li)1

Brachytherapy Intracavitary or Interstitial Implant Plan 8/8 9c.g i3
*Other (suggested): Plan a patient that is to be Simulated
and Treated on the same day (to experience time) 11
Not mandatory - strongly suggested

Please make sure to fill out the appropriate form in Typhon when the student completes a
1st Semester (Spring) —4 competencies must be completed
2" Semester (Summer) —6 competencies must be completed
3rd Semester (Fall) —7 competencies must be completed