Download Form Click HERE                                                   MRI Skills Checklist
Name Date   Yrs of Experience  
Registry No. Exp. Date        

Experience Credentials  
Experience Credentials  
Experience Credentials  
    4 = Proficient (at least two years of experience out of the last five) independent
  3 = Skilled (at least 6 months to one year within the last two years) minimal review needed
  2 = Intermittent Skills (less than 6 month out of the last two years) may need some supervision
  1 = Theory only No Experience


Are you competent in Pain Management and understand the JCAHO Guidelines?
Specialty Courses
1   Date
2   Date
3   Date
  Detail any additional experience or information you wish the hospital to know. Include your preferences of shift, area of assignment, and expectation of floating and any additional language that you speak.
  Please read and agree to the statements below.
*The information that I have provided in this skills checklist is true and accurate to the best of my knowledge and a true representation of my professional skills. I authorize PIC, Inc. to release this checklist to their client facilities for consideration of employment in a temporary or permanent capacity.