ࡱ> hkgK bjbj *0~8i~8i 88888LLLLDL'<(b'd'd'd'd'd'd'$*,b'8'88'mmm"88b'mb'mmr#T$P;h"#N''0'$z7-:7-$$&7-8$m''-@'7- X :  Applicant Observation Form Radiologic Technology Program 1300 Fifth Street, Wenatchee, WA 98801 To the applicant: You must observe a minimum of 8 hours with a Registered Radiologic Technologist RT (R). You may split up the timeframe to complete the full 8 hours. You are responsible for following instructions on how to schedule observations with each site and documenting all observation hours. Take this form with you and give it to the RT to complete and sign with the RTs signature. Submit this form with your application. Professional dress is required during the observation. Before beginning the observation, you must read and sign the Statement of Confidentiality. You must spend the majority of your observation time in the diagnostic radiology area. Observations spent solely in specialty imaging areas (such as: CT, MRI, ultrasound, mammography, nuclear medicine, and/or radiation therapy) will not be accepted. If the diagnostic imaging department is not busy on the day of the observation, you are strongly encouraged to schedule an additional observation. _____________________________________________________________________ PRINTED Applicant Name Observation Site: __________________________________________________________ Date(s) of Observation: _________________________ Total # of Observation Hours: __________ To the Radiologic Technologist: If the information provided above is correct, please complete the section below, sign the form, and return it to the student. Thank you for sharing your time and expertise. You may contact the Program Director if you have further comments regarding this applicant. The applicant must put on a lead apron for 10 minutes______ Assist/Observe in transporting patients_______ Carry IRs & accessory equipment______ Types of exams the applicant observed at this facility on the above date(s): ____Emergency ____Fluoroscopy ____Geriatric ____Outpatient ____Pediatric ____Portables ____Surgery ____Trauma ____Sterile Procedures Other: ______________________________________________________________________ The applicant: ____ Arrived on time _____Behaved professionally ____Showed interest. Additional comments about the applicant: _____________________________________________________________________________________ PRINTED RT Name RT Signature Date Claire Tompkins, MHL RT(R)(ARRT) WVC Radiography Program Director  HYPERLINK "mailto:ctompkins@wvc.edu" ctompkins@wvc.edu 509 682-6672  Radiologic Technology Program 1300 Fifth Street, Wenatchee, WA 98801 Statement of Confidentiality Healthcare providers are required by law to maintain patient confidentiality. Before observing in a radiology department, you must understand that you are responsible for treating information about patients and patient records with the upmost confidentiality. Following your observation experience, you must not talk about patients who were seen during your observation or about anything that pertains to the treatment of any patient. All patient care information is confidential. This form must be taken to each observation site to be signed by you and the radiology supervisor/lead before the start of your observation. The signed Statement of Confidentiality must be returned with your Applicant Observation Form. I understand that it is my responsibility to respect the confidentiality of patients and patient records, to follow procedures in order to protect patient privacy, and to act in a professional manner. I further understand that if I am found acting indiscreetly with confidential material or not protecting the privacy of a patient or others through my actions, I will be dismissed from the observation site immediately. Notification of my dismissal will be made to the Program Director. I recognize that this action is necessary in order to maintain high professional standards and integrity of the site in which I observe. Please review this form and any observation location rules with the radiology department supervisor. Applicants PRINTED Name _____________________________________________________ Applicants Signature ____________________________________________________________ Facility Name (do not abbreviate) __________________________________________________ Radiology Supervisor ____________________________________________________________ Claire Tompkins, MHL RT (R)(ARRT) WVC Radiography Program Director  HYPERLINK "mailto:ctompkins@wvc.edu" ctompkins@wvc.edu 509 682-6672    /012348UVWfwzʻʪ}ooaSEEEEhCJOJQJ^JaJhCJOJQJ^JaJh|tCJOJQJ^JaJhCJOJQJ^JaJh?CJOJQJ^JaJhCJOJQJ^JaJ hs5CJOJQJ\^JaJ h5CJOJQJ\^JaJh5CJOJQJ\aJ"hh5CJOJQJ\aJhCJOJQJaJhhCJOJQJaJjhU 2W] ^ h i &GHH^gd?p^pgdgd ^`gds   5 M k     ' < > T ` Ƶyyyyyykk]]]]hICJOJQJ^JaJhsCJOJQJ^JaJ&hs56CJOJQJ\]^JaJ&hI56CJOJQJ\]^JaJ&h56CJOJQJ\]^JaJ h6CJOJQJ]^JaJhCJOJQJ^JaJ h5CJOJQJ\^JaJh?h?CJOJQJaJhCJOJQJaJ$   ' [ `   Z ] ^ `    $ 7 > ? 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