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#0621-RH5010-01
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess one year paid work experience performing cardiac diagnostics procedures including echocardiograms?

Yes No
 

If you answered yes to question #1, identify the following:

  • Name of employer(s)
  • Position title(s) you possessed
  • Employment timeline(s)
  • Average hours worked per week
  • Duties performed
2.

Have you completed an approved training course in echogradiography technology or ultrasound technology?

Yes No
 

If you answered yes to question #2, identify the following:

  • Name of educational institution
  • Name of training course/program
  • Date of completion/graduation
3.

Are you currently certified as a Registered Diagnostic Cardiac Sonographer?

Yes No
 

If you answered yes to question #3, identify the following:

  • Type of certification
  • Certification number
  • Date of issuance
  • Expiration date
4.

 Are you currently certified as a Registered Cardiac Vascular Technician (RVT)?

Yes No
 

If you answered yes to question # 4, identify the following:

  • Type of Certification
  • Certifcation number
  • Date of issuance
  • Expriation date
5.

Are you currently certified as a Registered Diagnostic Medical Sonographer (RMDS) in good standing with the American Registry of Diagnostic Medical Sonography (ARDMS)?

Yes No
 

If you answered yes to questions 5, identify the following:

  • Type of certification
  • Certification number
  • Date of issuance
  • Expiration date