Joint Review Committee on Education in Radiologic Technology

20 N. Wacker Drive, Suite 2850

Chicago, IL 60606-3182

312.704.5300 ● (Fax) 312.704.5304

www.jrcert.org

APPLICATION FOR RECOGNITION OF A

CLINICAL SETTING IN RADIATION THERAPY

FORM 104T

Sponsoring Institution: / Program #

I. CLINICAL SETTING FOR WHICH JRCERT RECOGNITION IS SOUGHT:

Name
Address
City / State / Zip Code
This application must be completed for each clinical setting:
n  Consistent with JRCERT Policy 11.400, Procedure 11.405D - the JRCERT considers as a clinical setting all radiologic facilities under a single radiologic administration within the campus. A campus is defined as the buildings and grounds of a school, college, university, or hospital and does NOT include any geographically dispersed campus. Separate recognition is required for each facility not meeting this definition.
n  Enclose:
a. An affiliation agreement with Affiliation Agreement Criteria sheet (see page 4).
b. Form 102T for each designated clinical supervisor and all required attachments identified on the form.
c.  Documentation of current The Joint Commission (TJC) accreditation or equivalent. For clinical settings that are not accredited by TJC or equivalent, documentation of practice accreditation, for example American College of Radiology (ACR), and/or compliance with state and/or federal radiation safety regulations may be used.
n  An application for recognition is not guaranteed. Recognition may be denied, or the capacity authorized may be less than that requested by the program. Clinical total capacity is established by the JRCERT using the available resources identified within this form.
n  If the site is shared with other programs, all programs assigning students to this facility must coordinate schedules in order to assure that the clinical total capacity is never exceeded.
n  Fee - please see the current Fee Schedule at www.jrcert.org.

II. Clinical Supervisor(s):

Complete JRCERT Form 102T, and provide a current curriculum vitae, and documentation of current ARRT

registration or unrestricted state license for each individual listed. Duplicate and add additional page(s) as necessary.)

·  A minimum of one clinical supervisor must be identified for each clinical setting.

·  One full-time equivalent clinical supervisor must be identified for every ten (10) students involved in the

competency achievement process. (Standard Two, Objective 2.2)

Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials
Name / Degree/Credentials

Provide documentation of baccalaureate or higher degrees. (Although not required for clinical supervisors, the JRCERT database will reflect degrees only upon submission of appropriate documentation.) Submit documentation of degree attainment from an academic institution accredited by an agency recognized by the United States Department of Education (USDE) or the Council for Higher Education Accreditation (CHEA).

If degree documentation is not received for a clinical supervisor, it will be assumed that the program does not wish to have the degree noted.


III. CLINICAL CAPACITY

A.  The JRCERT will determine the clinical total capacity for this facility based upon the lower available resource identified as follows:

1. Please identify the total number of imaging rooms (physical resources) located on the campus of this facility, based upon the definition located on page one. This must NOT include Dosimetry equipment or patient care rooms.

a. The total number of treatment units is:

b. The total number of simulation units is:

a. plus b. equals a combined total of:

2. Identify the total number of qualified practitioners/radiation therapists (human resources) scheduled to be present on a typical day during the time of day that students will be on site:

B.  Please identify the number of students that the program is requesting to assign to the facility at any one time?

IV PROGRAM TOTAL CAPACITY:

A.  Based on the recognition of this facility, the program would like their program capacity to (select one):

remain the same OR increase by students

V. SIGNATURES

The following signatures constitute a request for JRCERT recognition of the facility as a clinical

setting and attests to the accuracy of all provide information:

RADIATION ONCOLOGY DEPARTMENTAL ADMINISTRATOR

Name (Print) / Title
Email Address

Signature

APPLICANT PROGRAM DIRECTOR

Name (Print) / Title

Signature

VI. AFFILIATION AGREEMENT CRITERIA:

Provide this completed page for the signed affiliation agreement submitted.

Sponsoring Institution: / Program #
Clinical Setting Name:

The affiliation agreement must:

Be current, check the expiration date.
Be signed by both parties.
Identify responsibility for PROFESSIONAL LIABILITY INSURANCE:
Page and Paragraph Number

NOTE: An affiliation agreement is not required for clinical settings owned by the sponsoring institution. In these instances; however, a memorandum of understanding is encouraged.

JRCERT Form 104T Clinical Setting Recognition / Revised: 7-27-15 / Page 2 of 4