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#0319-RH5004-A1
Supplemental Questionnaire

Last Name
First Name
1.

EXPERIENCE:


Do you possess two years experience performing diagnostics imaging in an acute care or medical clinical setting?

Yes No
 

If you answered yes to the above, identify the following:

  • Name of facility in which you gained the experience
  • Your position title
  • The duties performed
  • Your average hours worked per week
  • Your start and stop dates of employment

Note: if you possess experience at multiple facilities, list them all.

 

Identify your direct experience and demostrated competency in the functional areas of either radiography, fluoroscopy or CT scanning.

2.

LICENSES AND CERTIFICATES:

Are you currently registered with the American Registry of Radiologic Technologists (ARRT)?

Yes No
 

If you answered yes to the above, identify your ARRT ID number and expiration date.

 

Do you currently possess certification issued by the State of California Department of Health as a Radiologic Technologist?

Yes No
 

If you answered yes to the above question, identify your certification number and expiration date.

 

Do you possess current certification as a CT Technologist with the American Registry of Radiologic Technologist ARRT (CT)?

Yes No
 

If you answered yes to the above question, identify your certification number and the expiration date.