UCD School of Medicine
Scoil an Leighis UCD
UCD Health Sciences Centre
Belfield
Dublin 4
Ireland
Ionad Eolaíocht Sláinte UCD
Belfield
Baile Átha Cliath 4
Éire
T +353 1 716 6545/6546
F +353 1 716 6547
diagnostic.imaging@ucd.ie
www.ucd.ie/medicine
PRE-COURSE CLINICAL EXPERIENCE DECLARATION FORM
To be completed & returned within one month of the MSc / Grad Dip MRI programme start date.
Programme Applicant’s Details:
Name
Home Address
Employment
Address
Phone Number
E-mail Address
Programme Title
Please place a tick after the appropriate option:

Graduate Diploma in MRI

Taught MSc in MRI
Duration of Pre-course
Experience in MRI
Scope
of
Pre-course
Experience in MRI
Please continue on next
page
Please include the following information:
 Details of the MR scanner that you work with.
 Approx. number of patients scanned per day in your department.
 Types of MR examinations undertaken, e.g., neurological (brain / spine),
musculoskeletal, liver, pelvis, MR Angiography, cardiac etc.
 Contribution, where relevant, to education & training, protocol development,
research and/or other responsibilities in your MR department.
Please return completed form to:
Postgraduate Administrator, Diagnostic Imaging Office, Room A2.23,
Health Sciences Centre, University College Dublin, Belfield, Dublin 4.
E-mail: graduate.imaging@ucd.ie Fax: + 353 1 716 6547
UCD School of Medicine
Scoil an Leighis UCD
UCD Health Sciences Centre
Belfield
Dublin 4
Ireland
Ionad Eolaíocht Sláinte UCD
Belfield
Baile Átha Cliath 4
Éire
T +353 1 716 6545/6546
F +353 1 716 6547
diagnostic.imaging@ucd.ie
www.ucd.ie/medicine
PRE-COURSE CLINICAL EXPERIENCE DECLARATION FORM
(continued)
Scope of Pre-course
Experience in MRI
Continued from previous
page
I verify that the above named applicant has undertaken the minimum requisite pre-course experience in
MRI.
Name:
____________________
Signature:
________________________
Position:
____________________
Date:
________________________
Tel:
____________________
E-mail:
________________________
Please note that your Clinical Radiography Manager who signs to verify the information you provide in this
document may be contacted to confirm and /or clarify the scope of your MR scanning experience.
Please return completed form to:
Postgraduate Administrator, Diagnostic Imaging Office, Room A2.23,
Health Sciences Centre, University College Dublin, Belfield, Dublin 4.
E-mail: graduate.imaging@ucd.ie Fax: + 353 1 716 6547