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 RADIATION THERAPY
FORM 104T
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 102T for each designated clinical supervisor 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 104T Clinical Setting Recognition
Revised: 7-27-15
Page 1 of 4
II. Clinical Supervisor(s):
Complete JRCERT Form 102T, and provide a current curriculum vitae, and documentation of current ARRT
registration or unrestricted state license for each individual listed. Duplicate and add additional page(s) as necessary.)

A minimum of one clinical supervisor must be identified for each clinical setting.

One full-time equivalent clinical supervisor must be identified for every ten (10) 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 supervisors, 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 supervisor, it will be assumed that the program does not wish to
have the degree noted.
JRCERT Form 104T Clinical Setting Recognition
Revised: 7-27-15
Page 2 of 4
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 imaging rooms (physical resources) located on the campus of this facility, based
upon the definition located on page one. This must NOT include Dosimetry equipment or patient care rooms.
a. The total number of treatment units is:
b. The total number of simulation units is:
a. plus b. equals a combined total of:
2. Identify the total number of qualified practitioners/radiation therapists (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:
RADIATION ONCOLOGY DEPARTMENTAL ADMINISTRATOR
Name (Print)
Title
Email Address
Signature
APPLICANT PROGRAM DIRECTOR
Name (Print)
Title
Signature
JRCERT Form 104T Clinical Setting Recognition
Revised: 7-27-15
Page 3 of 4
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 104T Clinical Setting Recognition
Revised: 7-27-15
Page 4 of 4