UCD School of Medicine and Medical Science
Diagnostic Imaging
Scoil an Leighis agus Eolaíocht an Leighis
Iomháineas Fáithmheasta
Health Sciences Building
University College Dublin
Belfield, Dublin 4, Ireland
Ionad Na hEolaíochtaí Sláinte
An Coláiste Ollscoile, Báile Átha Cliath
Belfield, Báile Átha Cliath 4, Éire
CT Clinical Hours Declaration Form
Applicants Name
Applicants Home Address
Applicants Employment
Address
Mobile Phone Number
E-mail Address
Programme / Module
Please place a tic after the appropriate option:
Graduate Diploma in CT
Minimum of 700 hours (20+ weeks)
Taught MSc in CT
Minimum of 900 hours (26+ weeks)
Advanced CT Imaging module only
Minimum of 210 hours (6+ weeks)
I verify that the above named applicant has discussed the clinical placement requirements for their
chosen CT programme with me, and I agree to facilitate the student in achieving the specified hours.
RSM / CSR Signature:
Date: