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form
First Name
Last Name
Phone number
Email
Specialty:
General
Interventional
MSK
Neuro
Body Imager
Breast Imager/Mammographer
Current Practice situation:
Employee
Partner
Independent Contractor
Group size:
1-5
6-10
11-20
20+
Desired Practice Situation:
Remote
On-site
Hybrid
Earliest time of day you will begin work
Latest time of day you will work
Desired Practice relationship
Partnership
1099 Independent contractor
w2 employee with benefits
States licensed in:
Modalities done
CT-Head & Neck
CT-Abdomen & Pelvis
Ultrasound (US)
Plain Films (PF)
MRI-Body
MRI- Neuro
MRI- MSK
Any IR Procedures
Current Schedule:
Monday - Friday
7 on 7 off
other
Number of weekends per year
Number of weeks vacation
Current hours
Day (8 am to 5 pm)
Evening (4 pm to 12 midnight)
Overnight 12 midnight to 8 am
Call frequency
1 in 2
1 in 3
1 in 4
1 in 5
other
Current volume
Number of cases read daily
Current daily case mix
CT
US
MR
PF
Nucs
Mammo
Year board certified
Any malpractice or background issues?
Current income
Reason looking
What will better your situation
Attach CV
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