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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

CLINICAL SETTING (Disaffiliation/Deactivation/Reactivation) STATUS CHANGE FORM 106

Sponsoring Institution: Program #:

Type of Program (Check one): Radiography Radiation Therapy Magnetic Resonance Medical Dosimetry

Name of Clinical Setting:

Signature of Program Director:

Please change the status of the clinical education/practice setting as follows:

Disaffiliate Effective Date: A disaffiliated site is defined as a site no longer used as a clinical setting. The site will be removed from the program’s database. If the program decides to utilize this site in the future, the program must reapply for recognition.

Certificate of Recognition Enclosed Certificate Not Available How does this affect the program total capacity? (Check one):

Decrease by # No Change (Please explain where assigned students will be relocated)

Identify as Inactive Effective Date: An inactive site is defined as a site not currently in use; however, the program intends to use the site in the future. The program is responsible for all fees associated with the site during the inactive period.

How does this affect the program total capacity? (Check one):

Decrease by # No Change (Please explain where assigned students will be relocated)

Return this Site to Active Status Effective Date:

Maximum number of students that can be assigned at any one time:

How does this affect the program total capacity? (Check one):

No Change Increase by

Documentation required: Current affiliation agreement Current The Joint Commission (TJC) accreditation or equivalent Completed Form 102, with required attachments, for each clinical instructor/supervisor/preceptor JRCERT Form 106 Revised 3-2011 If the site is shared, complete JRCERT Form 1010R/T/MR, available at www.JRCERT.org

JRCERT Form 106 Revised 3-2011

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