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 INITIAL ACCREDITATION OF AN EDUCATIONAL
PROGRAM IN MEDICAL DOSIMETRY
FORM 100I-MD
Sponsoring Institution:
Program #
(To be assigned by JRCERT)
As of August 1, 2010, programs seeking initial accreditation must complete an Application for Initial Accreditation of an
Educational Program in Medical Dosimetry (Form 100I-MD). Once the application has been reviewed and reviewed by JRCERT
staff, program capacity will be determined and a due date for the self-study will be established. The program cannot enroll
students until the application has been reviewed by the JRCERT and program capacity identified.
Existing programs, which are those programs that have students enrolled prior to submission to the JRCERT of an Application for
Initial Accreditation and approval by the JRCERT of such application, must have graduated at least one cohort prior to being
eligible for JRCERT accreditation. Upon verification of a graduating cohort, the application will be reviewed by JRCERT staff.
Once reviewed, program capacity will be determined and a due date for the self-study will be established.
Programs are advised that review of the application takes approximately three (3) months. Once the application is reviewed, the
program may submit a self-study. The self-study review and scheduling of the site visit takes approximately 6-8 months. The
JRCERT will not conduct the site visit until students are in the clinical component of the program.
A partial application fee of $2,625 must be submitted with the application, with the balance of $1,050 of the initial application fee
due at the time of the self-study report submission. The program is responsible for all fees associated with the site visit. Prior to
scheduling the site visit, the program will be invoiced $1,500 as partial prepayment of site visit expenses. Programs are advised
that fees are non-refundable.
Programs must submit application(s) for all proposed clinical settings with the program application. The fee for initial application
includes the review and recognition of clinical settings received with and identified on the program’s application. No additional
fee is required. Each additional application received after submission of the program’s initial application will require a $250 fee.
These additional facilities may not be considered until the program has received initial accreditation. Students may not be
assigned to these facilities until the clinical settings are approved by the JRCERT.
Consideration of the application must include the following:
1. Institutional accreditation [e.g., accreditation by an agency recognized by the United States Department of Education
(USDE), Council for Higher Education Accreditation (CHEA) or The Joint Commission (TJC) or equivalent].
2. A qualified (Standard Six - Objective 6.2) program director and educational coordinator(s), if applicable.
3. Appropriate clinical setting(s) that provide a wide range of procedures for competency achievement.
4. Documentation of state approval to provide post-secondary education.
5. Submission of appropriate fees (see above).
 Complete Form 104I-MD (Application for Recognition of a Clinical Setting in Medical Dosimetry), pages 8-11 of this
application, for each clinical setting. (Copy form as needed.) Upon review of this material, the JRCERT will establish the
capacity at each.
 Complete Form 102MD (Application for Recognition of Program Officials in Medical Dosimetry), page 7 of this application,
for the program director, educational coordinator(s) and full-time didactic faculty (if applicable), and each clinical preceptor.
(Copy form as needed.)
 Programs are responsible for providing a copy of the application to each member of the site visit team.
 Program officials are encouraged to attend an accreditation seminar. Information may be obtained at www.jrcert.org
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 1 of 11
I. SPONSORING INSTITUTION:
Institution Type: (Check one)
4-year College or University
Community College
Technical College or Institute
Hospital
Military/Government
Consortium
Proprietary
The signatures of sponsoring institution/program officials constitute a request for initiation
of the accreditation process.
NOTE: By signing this application, you hereby affirm that you agree to comply with JRCERT policies and
provide prompt payment of all fees and costs associated with the application and site visit process.
Chief Executive Officer of Sponsoring Institution:
Name (Print)
Degree
Credentials
Title
Signature__________________________________________________________________________________________________
Mailing Address
City
State
Zip Code
E-mail address
Dean or Comparable Administrator (Radiation Oncology Administrator for hospital-based programs):
Name (Print)
Degree
Credentials
Title
Signature
Mailing Address
City
State
Zip Code
E-mail address
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 2 of 11
II. PROGRAM INFORMATION:
Mailing Address:
(If different from sponsor)
City
State
A. Resident tuition per academic year:
B. Award Granted:
Zip Code
$
Certificate
Degree(s)
Specify type(s):
C. Length of program:
months
D. Number of students enrolled per class:
Number of classes enrolled per year:
Date program intends to accept first class:
(mo.)
(yr)
Date students will begin clinical phase of program:
(mo.)
(yr.)
Date of graduation for first class:
(mo.)
(yr.)
E. Does the program have a Web page?
No
Yes
Web address
F. Alternative learning options:
a. Are more than four medical dosimetry courses in the program curriculum offered via distance or hybrid
delivery? * (NOTE: This does not include general education or pre-requisite courses.)
No
Yes
(If yes, please provide a narrative in Standard Three - Objective 3.2 that identifies
the courses and describes the method of distance/hybrid delivery.)
b. Does the program offer any of the following curricular tracks?*
No
Yes
Evening
(Check all that apply)
Weekend
G. Does the program have an articulation agreement with a postsecondary institution?
No
Yes
Name of institution
Credit applied toward
Associate degree
Name of institution
Credit applied toward
Associate degree
Part-time
Baccalaureate degree
Baccalaureate degree
H. Hospital-based Programs ONLY:
(NOTE: The JRCERT is responsible for oversight of Title IV funding for these programs only.)
Are students of the program eligible for Title IV student financial aid such as Pell Grants, Work Study,
Perkins Loans, Stafford Loans, Direct Loans, Plus Loans, and SEOG?
No
Yes
*Refer to Policy 10.800, Policy Statement 10.804
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 3 of 11
III. PROGRAM OFFICIALS:
Form 102MD, a current curriculum vitae, documentation of current MDCB registration (www.mdch.org) or equivalent.
Equivalent qualifications include certification by the ABR as a radiation oncologist or the ABMP as a medical physicist.
For those programs with an educational coordinator, the program director must provide, at a minimum, documentation of
ARRT registration in radiation therapy or an unrestricted radiation therapy state license.. Documentation of the
appropriate degree attainment from an academic institution accredited by an agency recognized by the United States
Department of Education or the Council for Higher Education Accreditation must be provided for the program director,
educational coordinator, and full-time didactic faculty. (Standard Six - Objective 6.2.)
Program Director:
Name (Print)
Degree
Credentials
Signature
Mailing Address
City
Area Code and Business Phone Number
State
zip code
Fax Number
E-mail Address
Educational Coordinator (if applicable): Required if the program director is not credentialed in medical dosimetry
or if the program has more than thirty (30) students enrolled in the clinical component.
Name (Print)
Degree
Credentials
Degree
Credentials
Physics Advisor (if applicable):
Name (Print)
Full-time Didactic Faculty (if applicable):
Name (Print)
Degree
Credentials
E-mail Address
Name (Print)
Degree
Credentials
E-mail Address
Name (Print)
Degree
Credentials
E-mail Address
Name (Print)
Degree
Credentials
E-mail Address
Name (Print)
Degree
Credentials
E-mail Address
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 4 of 11
IV. CLINICAL SETTINGS:
JRCERT Form 104I-MD (Application for Recognition of a Clinical Setting in Medical Dosimetry) must be completed
for recognition of each clinical setting. A minimum of one clinical preceptor must be identified for each clinical
setting. One full-time equivalent clinical preceptor is required for every five (5) students involved in the
competency achievement process [Duplicate and add additional page(s) if necessary]
List the requested clinical settings.
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 5 of 11
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Name of Clinical Setting
Address
Name of Clinical Preceptor(s)
Maximum number of students program requests to assign to this site at any one time:
For office use only, Do NOT Complete - JRCERT approved Clinical Total Capacity: _________
Program requested capacity
Program total capacity (to be established by the JRCERT): __________
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 6 of 11
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 PROGRAM OFFICIALS
IN MEDICAL DOSIMETRY
FORM 102MD
Sponsoring Institution:
Program #
(To be assigned by JRCERT)
Program Officials (Check one)
Consistent with JRCERT Policy 11.500, Procedure 11.501Biii, the sponsor is responsible for notifying the JRCERT of changes
in program officials within thirty (30) days of the change.
Program Director
e-mail address
telephone number
e-mail address
telephone number
e-mail address
telephone number
Educational Coordinator
Full-time Didactic Faculty
Clinical Preceptor
Name of Appointee:
Clinical Setting(s) (if applicable):
JRCERT #
Business Address:
Copies of the following must be attached:
 Current curriculum vitae/resume documenting compliance with Standard Six - Objective 6.2. Documentation of
professional experience must, at a minimum, contain the following:
1. Locations of employment in the professional discipline.
2. Month and year for start and end of employment at the identified location(s).
3. Titles of positions held during professional employment.

Current MDCB registration documentation or equivalent. The program may obtain this information from
www.mdcb.org. Equivalent qualifications are certification by the ABR as a radiation oncologist or the ABMP as a
medical physicist. For those programs with an educational coordinator, the program director must minimally provide
documentation of ARRT registration in radiation therapy or an unrestricted state license.

Documentation of the appropriate 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),
must be proved for program director, educational coordinator, and full-time didactic faculty. (Although not required for
clinical preceptors, the JRCERT database will reflect degrees only upon submission of appropriate documentation. 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 Staff Review ___________________________
Currently identified on JRCERT database
Date _________________________
Identified as Acting until __________
Curriculum vitae and other materials document compliance with Standard Six - Objective 6.2
Designate as acting (request a progress report for program directors and clinical coordinators only)
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 7 of 11
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 MEDICAL DOSIMETRY
FORM 104I-MD
Sponsoring Institution:
Program #
(To be assigned by JRCERT)
I.
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 102MD 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 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.
NOTE: This Form [104I-MD] located in the initial application (pages 8-11) can be used ONLY for the clinical
settings submitted with the initial application. Any subsequent applications for clinical setting recognition, must
use JRCERT Form 104MD, found on our Website at www.jrcert.org, attach supporting documentation, and
include the appropriate fee.
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 8 of 11
II. Clinical Preceptor(s):
Complete JRCERT Form 102MD, and provide a current curriculum vitae, and documentation of current MDCB
registration or unrestricted state license for each individual listed. Duplicate and add additional page(s) as necessary.)

A minimum of one clinical preceptor must be identified for each clinical setting.

One full-time equivalent clinical preceptor must be identified for every ten (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
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 100I-MD Application for Initial Accreditation
7/27/15
Page 9 of 11
III. CLINICAL CAPACITY
A. The JRCERT will determine the clinical total capacity for this facility based upon the number of qualified practitioners
(MDCB certification or equivalent dosimetrists) The ratio of students to staff shall not exceed 2:1:
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:
RADIATION ONCOLOGY DEPARTMENTAL ADMINISTRATOR
Name (Print)
Title
Email Address
Signature
PROGRAM DIRECTOR - PROGRAM SEEKING SITE RECOGNITION
Name (Print)
Title
Signature
JRCERT form 100I-MD Application for Initial Accreditation
7/27/15
Page 10 of 11
VI.
AFFILIATION AGREEMENT CRITERIA:
Attach a copy of this page to the front of each 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 100I-MD Application for Initial Accreditation
7/27/15
Page 11 of 11