UCD School of Medicine
& Medical Science
Scoil an Leighis agus
Eolaíocht 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
CLINICAL HOURS DECLARATION FORM
Programme Applicant’s Details
Name
Home Address
Employment
Address
Phone Number
E-mail Address
Programme Title
Please place a tick after the appropriate option:
Required MRI clinical hours

Advanced MR Imaging
(190 hrs / 6 wks)

Clinical & Professional Practice of MRI
(190 hrs / 6 wks)
I verify that the above named applicant has discussed the clinical placement requirements for their
chosen component modules of the MSc MRI programme with me, and I agree to facilitate the student in
achieving the specified hours.
Signature:
___________________________
Position:
___________________________
Please return completed form to:
Date:
_____________
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