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 OF A
CLINICAL SETTING IN MEDICAL DOSIMETRY
FORM 1010MD
Sponsoring Institution:
I.
Program #
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 number of dosimetrists available at
the facility:
1. Please identify the total number of dosimetrists (human resources) located on the campus of this facility. (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).
The total number of dosimetrists is:
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
JRCERT Form 1010MD Clinical Setting
Change
increase by
students
OR
Revised: 7-20-15
decrease by
students
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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 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.
VI. Clinical Preceptor(s):
Complete JRCERT Form 102MD- Recognition of Program Officials, and provide a current curriculum vitae, and
documentation of current MCDB registration or unrestricted state license for each individual identified.

A minimum of one clinical preceptor must be identified for each clinical setting.

One full-time equivalent clinical preceptor must be identified for every five (5) 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
JRCERT Form 1010MD Clinical Setting
Change
Revised: 7-20-15
Page 2 of 3
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 1010MD Clinical Setting
Change
Revised: 7-20-15
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