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

REACTIVATION AND/OR CLINICAL CAPACITY CHANGE OF A

CLINICAL SETTING IN RADIOGRAPHY

FORM 1010R

Sponsoring Institution: / Program #

I. CLINICAL SETTING FOR WHICH JRCERT REACTIVATION OR CAPACITY CHANGE IS SOUGHT:

Name
Address
City / State / Zip Code

II. 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 units (physical resources) located on the campus of this facility. This must NOT include Mammography, CT, MR, Ultrasound, Nuclear Medicine, Interventional, Cardiovascular, Bone Densitometry, or Therapy equipment. (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).

a. The total number of radiographic plus R&F rooms is:

b. The total number of mobile and c-arm units is:

a. plus b. equals a combined total:

2. Identify the total number of qualified practitioners/radiographers (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.?

III. PROGRAM TOTAL CAPACITY:

A.  Based on the reactivation or requested change in clinical capacity of this facility, the program would like their program capacity to (select one):

remain the same OR increase by students OR decrease by students

IV. SIGNATURE

The following signature constitute a request for JRCERT reactivation and/or change in clinical capacity of this facility as a clinical setting and is accurate to the best of my knowledge:

PROGRAM DIRECTOR

Name (Print) / Title

Signature

.

ONLY COMPLETE THIS PORTION FOR REACTIVATION

OF CLINICAL SETTINGS

V. PLEASE SUBMIT THE FOLLOWING:

A current affiliation agreement with completed Affiliation Agreement Criteria sheet [page three (3)].

Documentation of current The Joint Commission (TJC) accreditation or equivalent for the clinical setting. For clinical settings that do not hold accreditation by TJC, documentation of compliance with state and/or federal radiation safety regulations may be used as equivalent.

California programs - a copy of a current Radiation Machine Tube Registration.

VI. Clinical Instructor(s):

Complete JRCERT Form 102R- Recognition of Program Officials, and provide a current curriculum vitae, and documentation of current ARRT registration or unrestricted state license for each individual identified.

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

·  One full-time equivalent clinical instructor 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

VII. AFFILIATION AGREEMENT CRITERIA:

Attach a copy of this page to the front of the signed affiliation agreement.

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 1010R Clinical Setting Change / Revised: 7-20-15 / Page 3 of 3