Accuboost Positioning Training Verification Form

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MEDICAL RADIOLOGIC TECHNOLOGY
BOARD OF EXAMINERS
Brian D. Goretzki, Chairman
Shanna Farish, Executive Director
th
4814 South 40
Street
Phoenix, AZ 85040-2940
Phone: (602) 255-4828
Fax: (602) 437-0704
AccuBoost Positioning Training Verification Form
Name________________________________Facility___________________________________
CTT#___________________________Expiration Date___________________
Facility Address _______________________________________________________________
_______________________________________________________________
Phone number__________________________Fax Number___________________________
(Copy will be faxed and mailed to facility)___________________________________________________________________________
Section 1
Date of Training___________________________________________________
Hours of Training __________(Minimum of 4 Hours)
Place of Training__________________________________________________
CMT Trainer Name________________________________________________
CMT#___________________________Expiration Date__________________
Place(s) of Employment for past 5 year
(Must have been performing mammography for past 5 years)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Section 2
How many positioning demonstrations have been completed for each of the below positions? Please
check box for each position trainee has demonstrated proficiency in.
(A minimum of 10 demonstrations is
required for CC and lateral)
⎕ CC Number of demonstrations ________________
⎕ MLO Number of demonstrations_______________
⎕ Lateral Number of demonstrations______________
I, ___________________________________ have trained ___________________________
In positioning for the AccuBoost system. I verify he/she is capable of positioning correctly.
_____________________________________
__________________
For MRTBE use only
CMT Trainer Signature
Date
_____________________________________
__________________
CTT Trainee Signature
Date
Date____________
Division of Arizona Radiation Regulatory Agency
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