Important Changes to Recognition of Clinical Setting Application Form 104MR
Please begin utilizing the revised forms immediately.
The form is on the following pages.
If you have any questions contact the office for assistance.
The JRCERT is constantly updating our accreditation forms to make certain that the forms request only the information needed to
evaluate program requests. Upon further review of the application for recognition of clinical settings we have determined that the
current form can be simplified as follows:
1. The signature of the institution’s president or CEO is no longer required on the form because their signature is already on
the affiliation agreement.
2. JRCERT policy has been changed to eliminate the 90-day early termination clause, and the student supervision
requirements. The new form only requires a fully signed affiliation agreement that outlines the responsibilities of both
entities, and addresses student liability.
3. Rather than identify each individual piece of equipment, programs are asked to provide only the total number of units
available at the facility.
4. Rather than identify each individual staff member and their shift worked, programs are asked to provide only the total
number of clinical staff available during the time of day that students are present.
5. Programs are required to provide only the total number of students they intend to send to the facility at any one time.
6. Shared settings – Please understand that it is the prerogative of each clinical setting to contract with whomever they
choose. It is not within the purview of the JRCERT to deny additional affiliations with a clinical setting by additional
programs.
a. The JRCERT may deny an application if there are insufficient resources.
b. The JRCERT will continue to identify the clinical capacity of each setting by evaluating the available physical
and human resource totals provided in the application.
c. Currently recognized programs will no longer be asked to review the information provided by the applicant
program or sign the application. All programs recognized for student placement are expected to cooperate in
coordinating schedules to assure that the clinical capacity is never exceeded.
d. Currently recognized programs will continue to receive copies of JRCERT correspondence to applicant programs
regarding shared clinical settings.
The JRCERT relies upon program directors to provide accurate information when submitting applications. Additionally, as
changes occur at the clinical setting, it is the program director’s responsibility to respond accordingly to change. For example,
if a setting has experienced a reduction in procedure volumes, the initially identified clinical capacity may no longer be
appropriate. Programs may find it necessary to remove students and place them at different settings until procedure volumes
return to a sufficient level in order to meet the clinical educational needed of the assigned students.
JRCERT Form 104MR Clinical Setting
Recognition
Revised: 7-8-15
Page 0 of 5
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
APPLICATION FOR RECOGNITION OF A
CLINICAL SETTING IN MAGNETIC RESONANCE
FORM 104MR
Sponsoring Institution:
I.
Program #
CLINICAL SETTING FOR WHICH JRCERT RECOGNITION IS SOUGHT:
Name
Address
City
State
Zip Code
This application must be completed for each clinical setting:
 Consistent with JRCERT Policy 11.400, Procedure 11.405D - the JRCERT considers as a clinical setting
all radiologic facilities under a single radiologic administration within the campus. 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.
 Enclose:
a. An affiliation agreement with Affiliation Agreement Criteria sheet (see page 4).
b. Form 102MR for each designated clinical preceptor and all required attachments identified on the form.
c. Documentation of current The Joint Commission (TJC) accreditation or equivalent. 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.
 An application for recognition is not guaranteed. Recognition may be denied, or the capacity authorized may
be less than that requested by the program. Clinical total capacity is established by the JRCERT using the
available resources identified within this form.

If the site is shared with other programs, all programs assigning students to this
facility must coordinate schedules in order to assure that the clinical total capacity
is never exceeded.
 Fee - please see the current Fee Schedule at www.jrcert.org.
JRCERT Form 104MR Clinical Setting
Recognition
Revised: 7-8-15
Page 1 of 5
II. Clinical Preceptor(s):
Complete JRCERT Form 102MR, and provide a current curriculum vitae, and documentation of current ARRT
registration or unrestricted state license for each individual listed.

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
Name
Degree/Credentials
Name
Degree/Credentials
Name
Degree/Credentials
Name
Degree/Credentials
Name
Degree/Credentials
Name
Degree/Credentials
Name
Degree/Credentials
Name
Degree/Credentials
Provide documentation of baccalaureate or higher degrees. (Although not required for clinical preceptors, the JRCERT
database will reflect degrees only upon submission of appropriate documentation.) Submit documentation of degree
attainment from an academic institution accredited by an agency recognized by the United States Department of
Education (USDE) or the Council for Higher Education Accreditation (CHEA).
If degree documentation is not received for a clinical preceptor, it will be assumed that the program does not wish to have
the degree noted.
JRCERT Form 104MR Clinical Setting
Recognition
Revised: 7-8-15
Page 2 of 5
III. CLINICAL CAPACITY
A. The JRCERT will determine the clinical total capacity for this facility based upon the lower available resource
identified as follows:
1. Please identify the total number of magnets (physical resources) located on the campus of this facility, based upon
the definition of campus located on page one.
2. Identify the total number of qualified practitioners/magnetic resonance technologists (human resources) scheduled
to be present on a typical day during the time of day that students will be on site:
B. Please identify the number of students that the program is requesting to assign to the facility at any one time?
IV PROGRAM TOTAL CAPACITY:
A.
Based on the recognition of this facility, the program would like their program capacity to (select one):
remain the same
OR
increase by
students
V. SIGNATURES
The following signatures constitute a request for JRCERT recognition of the facility as a clinical
setting and attests to the accuracy of all provide information:
RADIOLOGY DEPARTMENTAL ADMINISTRATOR
Name (Print)
Title
Email Address
Signature
APPLICANT PROGRAM DIRECTOR
Name (Print)
Title
Signature
JRCERT Form 104MR Clinical Setting
Recognition
Revised: 7-8-15
Page 3 of 5
VI.
AFFILIATION AGREEMENT CRITERIA:
Provide this completed page for the signed affiliation agreement submitted.
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 104MR Clinical Setting
Recognition
Revised: 7-8-15
Page 4 of 5