ADVANCED MODALITY SELECTION FORM
Name (Print): __________________________________________ Date: ___________________
Please indicate/check the option you would like to pursue (Check only one):
You may select one advanced modality (in addition to Radiography, which is required)
listed below.
______ MRI: (1 day clinic, 1 class meeting/week; 2 semesters (Fall/Spring); 2 days
clinic, 1 class meeting/week – Summer- 12 crh).
______ CT: (1 day clinic, 1 class meeting/week; 2 semesters (Fall/Spring); 2 days
clinic, 1 class meeting/week – Summer-12 crh).
______ Mammography: (1 day clinic, 1 class meeting/week; 2 semesters
(Fall/Spring); 2 days clinic, 1 class meeting/week – Summer-12 crh).
______ Vascular Radiography: (1 day clinic, 1 class meeting/week; 2 semesters
(Fall/Spring); 2 days clinic, 1 class meeting/week – Summer-12 crh).
______ Radiology Administration (2 online classes – Fall & Spring, Preceptorship
Summer – total 3 semesters – 13 crh.)
The options below may not be taken with other modalities. Select only one.
______ Ultrasound
______ Radiation Therapy
If you are not selected for your first choice in modalities, do you have a second choice? If
so, please indicate what your second choice would be.
___________________________________
**Please note that the number of slots available in each modality is limited to the number
of clinical spaces available.
Student Signature
Revised 2014
Return this form to Dr. Newell