Affiliated Clinical Site Application Attachment Instructions
Statement of Financial Liability
Provide proof that there is no law enforcement action pending against the laboratory.
Current RHB Registration
Scan and submit the site's current RHB registration as assigned by the State.
Machine Inventory
Radiation machine registration number of the clinical site as indicated on the certificate of registration issued to the site for purposes of Article 1 (commencing at section 30108), Group 1.5 of subchapter 4.0.
Site Map
Clinical Affiliated Site Map must include the following:
List of Processing Equipment
List of all processing equipment used at the site.
Proof of Current Employee Postings
Provide a copy of each faculty member’s certificate/permit, current Curriculum Vitae/resume, and any degree(s) earned.
Proof of Current Postings
Radiation Protection Program
Submit Radiation Protection Program that meets standards of Title 17 Section 30420 - Radiation Protection Program and the policies of the AADMRT Online RPP.
Establish ACS Radiation Safety Officer
Each ACS must establish their own RSO. That “ACS RSO’s” authority is derived from the obligation of the CEO and Administrative RSO to ensure a safe environment for students, staff and visitors in conformance with State and Federal radiation control regulations. Once the ACS Radiation Safety Officer is established, submit the individual's curriculum vitae and sign the RSO Job Description Agreement.
Determine Total Clinical Capacity (TCC)
Determine the number of students in compliance with CA Code of Regulations Title 17 Section 30414 - Approval as an Affiliated Clinical Site. An approved school may not allow the total number of students at a clinical site to exceed the total clinical capacity (TCC) calculated as follows:
(1) For diagnostic radiologic technology (RT) schools and limited permit (LP) X-ray technician schools (except that an LP school teaching the category of dermatology X-ray therapy shall use the calculation in subsection (c)(2)):
TCC = the lesser of A or B where:
Note: Authority cited: Sections 114870(a) and 131200, Health and Safety Code. Reference: Section 114870, 131050, 131051 and 131052, Health and Safety Code.
Form CDPH 9053 (AADMRT Online submits this)
Provide proof that there is no law enforcement action pending against the laboratory.
Current RHB Registration
Scan and submit the site's current RHB registration as assigned by the State.
Machine Inventory
Radiation machine registration number of the clinical site as indicated on the certificate of registration issued to the site for purposes of Article 1 (commencing at section 30108), Group 1.5 of subchapter 4.0.
Site Map
Clinical Affiliated Site Map must include the following:
- Numbered machine locations
- Emergency stop buttons
- Emergency breaker locations
- First-aid kit locations
- Emergency escape route (indicate location of stairs if necessary)
List of Processing Equipment
List of all processing equipment used at the site.
Proof of Current Employee Postings
Provide a copy of each faculty member’s certificate/permit, current Curriculum Vitae/resume, and any degree(s) earned.
Proof of Current Postings
- Caution Radiation (entry to each x-ray room)
- RHB Notice to all Employees
- Emergency Procedures
- Machine Operation Guidelines
Radiation Protection Program
Submit Radiation Protection Program that meets standards of Title 17 Section 30420 - Radiation Protection Program and the policies of the AADMRT Online RPP.
Establish ACS Radiation Safety Officer
Each ACS must establish their own RSO. That “ACS RSO’s” authority is derived from the obligation of the CEO and Administrative RSO to ensure a safe environment for students, staff and visitors in conformance with State and Federal radiation control regulations. Once the ACS Radiation Safety Officer is established, submit the individual's curriculum vitae and sign the RSO Job Description Agreement.
Determine Total Clinical Capacity (TCC)
Determine the number of students in compliance with CA Code of Regulations Title 17 Section 30414 - Approval as an Affiliated Clinical Site. An approved school may not allow the total number of students at a clinical site to exceed the total clinical capacity (TCC) calculated as follows:
(1) For diagnostic radiologic technology (RT) schools and limited permit (LP) X-ray technician schools (except that an LP school teaching the category of dermatology X-ray therapy shall use the calculation in subsection (c)(2)):
TCC = the lesser of A or B where:
- A = total number of qualified practitioners, as defined in section 30400, at the clinical site who provide direct or indirect oversight.
- B = total number of available physical resources determined as follows:
- B = R
- R = One times the total number of radiography only rooms
Note: Authority cited: Sections 114870(a) and 131200, Health and Safety Code. Reference: Section 114870, 131050, 131051 and 131052, Health and Safety Code.
Form CDPH 9053 (AADMRT Online submits this)
| CDPH 9053 |
Affiliated Clinical Site Agreement
Print and send ACS Agreement to the headquarters only if approved by AADMRT Online.
Print and send ACS Agreement to the headquarters only if approved by AADMRT Online.
| ACS Agreement |