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University of Utah Health - Radiology Observation Tracking Form
1.
Observation Information:
Technologist Name:
Student Observer Name:
Name/Location of Clinical Site:
Total Number of Hours Observing:
2.
Imaging Modality:
Diagnostic Radiology (x-ray)
Sonography/Ultrasound
Nuclear Medicine
MRI
CT
Mammography
3.
Date of Observation:
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
4.
Please rate the observer for the following categories:
Poor
Average/Satisfactory
Excellent
Professionalism
Poor
Average/Satisfactory
Excellent
Curiosity/Questions
Poor
Average/Satisfactory
Excellent
Engagement
Poor
Average/Satisfactory
Excellent
Communication/Interpersonal
Poor
Average/Satisfactory
Excellent
Respect for Patients/Staff/Confidentiality
Poor
Average/Satisfactory
Excellent
Comments regarding scoring:
5.
Do you support this candidate for admittance to their Imaging Program?
Yes
No
Unsure
Comments:
6.
Please note any strengths, weaknesses, areas for concern and any other general comments that the application review team should be aware of.
Current Progress,
0 of 6 answered
