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BIC Training Waiver Request

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BIC Training Waiver Request Powered By Docstoc
					                              Documentation of Past MRI Operator Experience
                                                   MU Brain Imaging Center

Name: _______________________________________________                       Date:______________________________
Current University (if not MU): ___________________________________________________________________
Primary Department: ___________________________________                     School:____________________________
Current Position/Title: ______________________________________              Highest Degree Earned: ______________

                                    _____Past Formal Training in MRI Operation_____

Have you previously completed a JRCERT-accredited training program in radiologic technology? Yes             No
            If yes, please identify the program & your graduation date: _________________________________________
            If yes, do you also have ARRT certification?   Yes    No
Have you met the ARMRIT and/or ACR accreditation requirements as an MRI technologist? Yes               No

                                     _____Past Informal Training/Experience (#1) _____

Location: _______________________________________________Dates (inclusive): _________________________
Make, Model, & Field Strength of Scanner Used: _______________________________________________________
Was a licensed MR technologist present to assist you in operating the scanner?      Yes    No
What was your primary role?
            ___ Observed scans
            ___ Oversaw/directed data collection but other MR technologist was responsible for actual operation the scanner
            ___ Operated the scanner interface yourself w/o another MR technologist’s immediate supervision
Other Comments: ________________________________________________________________________________
_______________________________________________________________________________________________


                                     _____Past Informal Training/Experience (#2) _____

Location: _______________________________________________Dates (inclusive): _________________________
Make, Model, & Field Strength of Scanner Used: _______________________________________________________
Was a licensed MR technologist present to assist you in operating the scanner?      Yes    No
What was your primary role?
            ___ Observed scans
            ___ Oversaw/directed data collection but other MR technologist was responsible for actual operation the scanner
            ___ Operated the scanner interface yourself w/o another MR technologist’s immediate supervision
Other Comments: ________________________________________________________________________________
_______________________________________________________________________________________________



I attest that the information provided above is accurate to the best of my knowledge.


__________________________________________________                          ____________________
Signature                                                                   Date

				
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