Name of Facility:   

Address1:   

Address2:   

City:   

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Contact Name:   

Email Address:   

Main Phone Number:               Lab Phone Number:   

How did you find out about us?
           

Please check all that apply.

1. What is important to your practice?
        Ability to call up last minute to get a Temp for an assignment.
        Ability to call up in advance and schedule a Temp for a scheduled assignment.

2. What are your facilities hours of operation?
           

3. What qualifications do you require of a temporary sonographer?
        Registered Diagnostic Medical Sonographer (RDMS, RVT, RDCS)
        Pending Certification
        Either is acceptable, providing they are experienced.

4. What is an acceptable dress code for a temp sonographer at your facility?
        Professional clothes under a lab coat.
        White uniform & lab coat
        Colored/floral scrubs
        Other:   

5. How often are patients scheduled for ultrasound examinations?
        Every 30 minutes
        Every 45 minutes
        Every hour

6. What is the average ultrasound patient load, per sonographer, on a typical day at your facility?
        3-4 patients
        5-10 patients
        10-15 patients
        15-20 patients
        Greater than 20 patients

7. When Ultrasound Temps Inc. provides coverage to your facility, would the temporary sonographer be working alone or with other sonographer’s in the department?
        Alone in the department
        With other sonographers
        Other:   

8. How many ultrasound scanning stations do you use at your facility?
        One
        Two
        Three
        More than Three

9. What type of ultrasound equipment do you use in your laboratory?

GE          Philips          Hewlett Packard          Siemans          Toshiba          Sonosite		Aloka   ATL   Diasonics   Interspec (Apogee)   Corometrics
Other type of machines:

10. What type of ultrasound is performed in your laboratory?

Abdomen:

Complete Abdomen         Abdominal Doppler         Renal         Aorta		Ultrasound Guided Procedures   Transplant Organs
Other:

Superficial Structures:

Breast         Thyroid         Scrotum		Musculoskeletal   Abdominal Wall   Neonatal Heads
Other:

Obstetric:

OB Complete             1st Trimester OB             2nd/3rd Trimester OB         Biophysical Profile		OB Doppler   Ultrasound Guided Procedures       Amniocentesis       Chorionic Villi Sampling
Other:

Gynecology:    

Transabdominal Pelvis         Transvaginal Pelvis             Follicular Monitoring		Uterine/Ovarian Doppler   Sonohysterography
Other:

Vascular:

Venous Imaging             Lower Extremity             Upper Extremity         Carotid Doppler         Abdominal Doppler

PVR (Arms & Legs)   IPG (Arms & Legs)   Arterial Imaging             Lower Extremity             Upper Extremity

Other:

Echo:

2-D & M Mode              Adult             Pediatric         Stress Echo or TEE		EKG   ECG   Holter Monitoring
Other: