Name of Facility:   

Address:   

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?
        Being able to call up last minute to get a replacement.
        Being able to call up in advance and schedule a Temp.

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 temp sonographer’s 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 machines do you use at your facility?
        One
        Two
        Three
        More than Three

9. What type of ultrasound equipment do you use at your practice?

Accuson          Accusonics (AI)          Aloka          ATL          Diasonics          GE		Hewlett Packard   Interspec (Apogee)   Corometrics   Phillips   Siemans   Toshiba
Other type of machine:

10. What types of ultrasounds are performed at your laboratory?

Abdomen:

Complete Abdomen         Invasive Procedures         Doppler		Renal   Transplant Organs
Other:

Small Parts:

Breast         Prostate         Transrectal

Testicles   Thyroid   Neonatal Heads

Obstetric:

OB Complete         Biophysical Profile         OB Doppler		Guided Procedures   Amniocentesis   Chorionic Villi Sampling
Other:

Gynecology:
        Transvaginal
        Follicular Monitoring
        Other:   

Vascular:

Venous Imaging         Lower Extremity         Upper Extremity         Arterial Imaging         Lower Extremity

Upper Extremity   Arterial Pulse Volume Recording   Penile Imaging   Carotid Doppler

Echo:
        2-D Echo
        Stress Echo or TEE
        Other: