Resident Name__________							Date_____
Examiner__________
1. Assembly
○ Able to assemble scope correctly								No		Yes (3)
○ Chooses correct sheath size (17f)								No		Yes (3)
○ Chooses correct Lens (70 deg pref. 30 deg OK)								No		Yes (3)
○ Overall Technique (Efficiency)
poor				1	2	3	4		5	excellent
Time__________
Comments____________________
2. Bladder Survey Task
○ Chooses correct fluid (Sterile Water)								No		Yes (3)
○ Places sheath with obturator first or with H20 running								No		Yes (3)
○ Observes all regions of bladder (Dome, Trigone, L&R sides)								No		Yes (3)
○ Identifies ureteral orifices (U.O.)								No		Yes (3)
○ Attempts to observe urine flow from each UO								No		Yes (3)
a. Identifies lack of flow from one ureter								No		Yes (3)
○ Indicates use of Indigo to clarify urine flow								No		Yes (3)
○ Identifies abnormality and its location								No		Yes (3)
○ Surveys urethra on completion								No		Yes (3)
a. Uses proper lens (0 deg)								No		Yes (3)
3. Overall Technique
poor	1	2	3		4	5	excellent
4. Overall assembly and survey time__________
Comments____________________
Overall Score (out of 49) __________________