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without written permission from ISFER. All rights reserved IFSER Rev.01/2012 Statement: I certify the accuracy of these verifiable examination numbers confirmed through review of Clinical Log records. I have personally scanned, either assisting or completing, the following number of examinations between the period of ________(month), __________(year) and ___________(month), ___________(year).

___________________________________ ________________________________ ____________________

Signature of Learner Signature of Reviewer Date

Examination
CLINICAL CONDUCT & BEHAVIOR EMPLOYEE FUNCTIONS BODY DYNAMICS SONOGRAPHYER / PATIENT INTERACTION PATIENT AND SONOGRPAHER SAFETY

Totals

Totals

PROFESSIONAL QUALITIES / PATIENT CARE Name__________________________________

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