University of Wisconsin-La Crosse Medical Dosimetry Program Competency Check list Competencies CANNOT be performed on datasets they must

be performed on real patients

Student Name:_______________________________________________________ Clinical Site:_________________________________________________________

Competency First Rotation Palliative Para-aortic or nodal irradiation Pelvis-4 field Abdomen-3 or 4 field Off-axis prescription point Pelvis-3 field Second Rotation Palliative Intact Breast Tangentials Chest Wall Tangentials (bolus: non-bolus weighting) Breast or Chest wall with sclav and PAB Thoracic (Conformal) Limb Sarcoma Lymphoma Prostate (IMRT or conformal)* True Vocal Cord Third Rotation Palliative H & N (IMRT or conformal)* Electron Beam Plan Brain (IMRT or conformal)* Esophagus (IMRT or conformal)* Intracavitary Implant plan Interstitial Implant Plan Other:

Evaluators initials

Date Performed

*The competencies with the asterisk can be done on either an IMRT plan OR a conformal plan. Please make sure you fill out the appropriate form when completing the competency.