CCSF's DMI Program Application

Diagnostic Medical Imaging
Program Application

All components and questions in this application must be complete in their entirety to be eligible for consideration for admissions into the DMI program. You may save your progress at any time and continue later. Once the application is completely filled out, you may submit the application. After submitting the application, no edits can be made. If you have any problems with the form, email us at dmi@ccsf.edu.

Applicant Information
Applicant Information
First Name*
First Name
Last Name*
Last Name
Preferred First Name*
Preferred First Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Phone Number
Personal Email (non-CCSF email)*

Confirmation Email
CCSF Student Information

If you do not have a CCSF Email or CCSF Student ID Number, you will need to apply to CCSF.
CCSF Email*

Confirmation Email
CCSF Student ID Number*
W00000000 or @00000000

Volunteer Hour Verification
Volunteer Hour Verification

The purpose of the 40-hour volunteer requirement is to expose a prospective applicant to the work environment of a hospital and the duties, tasks, and skills required of a radiographer. When an applicant is considering the investment of the time, effort, and resources to learning a new profession, it is imperative to invest substantial effort to research the field to determine whether it is a suitable career choice. To that end, applicants are required to experience some time in a radiology department to observe radiographers at work performing general radiographic procedures.

Instructions
- Bring this Volunteer Hour Verification Form with you while you volunteer. Technologists will need to sign and verify your required hours.
Upload the completed Volunteer Hour Verification Form*

PDF files only
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Complete the table below based on your volunteer experience. *

	Exam Observed	Age	Gender	Reason for Exam
1
2
3
4
5
6
7
8
9
10

Radiography Profession Questions
Radiography Profession Questions

The purpose of the radiography profession questions is to expose a prospective applicant to the radiography profession. Radiologic Technologists interact with the community and expose them to radiation. Understanding the basics of radiation and how to properly communicate with the public are essential skills of a Radiologic Technologists. An applicant can use any means available to answer the following questions.

Instructions
- Provide a brief original answer to each question.
- Application screening includes the quality of answers which indicate your research into radiography. Two or more incorrect or poorly answered questions are grounds for disqualification due to a lack of research and interest in the profession.
- Your written communication skills are expected to be at the college level. “Yes” or “no” responses are not acceptable.
1. Describe both the educational background and job description of a Radiologist.*
2. Describe both the educational background and job description of a Radiologic Technologist.*
3. Describe both the educational background and job description of an X-Ray Technician.*
4. Communication is critical between radiologic technologists, patients, co-workers, and providers. Explain in detail how your spoken and written communication skills are at the appropriate level for this profession.*
5. How do Radiologic Technologists ensure radiation safety for themselves and their patients? Describe specific practices or protocols used in the field.*
6. Does radiation remain in the room or in the patient after the exposure has been made? If yes, for how long; if no, where does it go?*
7. What do you perceive to be the primary responsibilities and daily tasks of a Radiologic Technologist, and how does this role differ from other medical imaging professionals?*
8. Is there anything radioactive within the diagnostic x-ray tube? If yes, what type of radiation? If no, how is the radiation created? *
9. Radiography can be a demanding profession. Describe a situation where you had to manage a high-stress or high-workload environment and how you coped with it.*
10. Provide an example of a time when you had to work collaboratively in a team setting. How do you view the importance of teamwork in the field of radiography? *

Academic Requirements
Colleges/Universities Attended
In the text box below, list all colleges/universities you have attended. If accepted into the program, you must provide official transcripts from the colleges listed here.*
Unofficial Transcripts

You must upload all unofficial domestic and international transcripts from every college/university you attended and all College Board transcripts with AP test results of three or higher. You must upload an unofficial transcript if you took courses at CCSF. If accepted into the program, you must provide official domestic and international transcripts to the DMI program.

Domestic Transcripts
- Each unofficial transcript must include your name and the college's name
- Upload unofficial transcripts from all colleges/universities you have attended
International Transcripts
- International transcripts must be evaluated prior to submitting an application
- Contact graduate@ccsf.edu regarding international transcripts
Upload unofficial transcripts from every college/university attended*

PDF files only
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Prerequisite Courses to Complete Before Application

These courses must be completed before applying to the program. These courses must be completed within seven years of the application date, with the exception of English. English does not have an expiration date. If any of these courses were taken not at CCSF, you may need to complete a Course Equivalency Form.

Select the proper answer for each requirement.*

	I completed this requirement at CCSF	I completed this requirement somewhere other than CCSF	I have not completed this requirement
General College Chemistry Lecture
General College Chemistry Lab
English
Human Anatomy Lecture
Human Anatomy Lab
Human Physiology Lecture
Human Physiology Lab
Intermediate Algebra (or acceptable alternate courses)
Introductory Physics Lecture
Introductory Physics Lab

Type a question
Course Equivalency Form

If you completed all requirements at CCSF, you do not need to submit a Course Equivalency Form.
Course Equivalency Form

If you completed any requirements somewhere other than CCSF, you must complete a Course Equivalency form. Follow these directions:
1. Download Course Equivalency Form
2. Fill out the "To be completed by student" section
3. Email the Course Equivalency Form and appropriate course description and unofficial transcript to the appropriate CCSF department chair (ex. math course equivalency forms go to CCSF's math department chair)
4. Upload Completed Course Equivalencies (required)
Upload completed Course Equivalency Form(s)

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Highly Recommended Courses to Complete Before Application

These courses are not required to be completed before applying to the program; however, these courses serve as prerequisites or corequisites to DMI courses as early as the first semester of the program. These courses do not have to be completed within seven years of the application date.
Check the box for each course you have successfully completed and passed (completion or non-completion of these courses is not a considering factor when reviewing your application).

Advanced First Aid and Basic Life SupportIntro to Radiologic Technology at CCSFMedical TerminologyPsychologyPublic Speaking
Academic History

Academic history of more than two incomplete grades, withdrawals, or repetition within the past seven years of courses listed under "Prerequisite Courses to Complete Before Application," due to failures, academic probation, etc., may be cause for application disqualification. More than two are considered excessive by the DMI program and an indication of academic problems.
- If you have more than two incomplete grades, withdrawals, and/or repetition of "Prerequisite Courses to Complete Before Application" within the past seven years, explain the reasons for your academic history. This explanation is not a guarantee of admission, however, it will be taken into consideration.
- Any incomplete grades, withdrawals, repetition of "Highly Recommended Courses to Complete Before Application" shall not be counted toward the academic history of more than four incomplete grades, withdrawals, repetition courses.
Do you have more than two incomplete grades, withdrawals, and/or repetition of "Prerequisite Courses to Complete Before Application" within the past seven years*

YesNo
If you selected "Yes" above, explain the reason(s) for the incomplete grades, withdrawals, and/or repetition of prerequisite courses. (required)
Radiographic Science Program History
Have you ever voluntarily withdrawn from a radiologic science program?*

YesNo
If you selected "Yes" above, describe what actions you have taken to ensure success if admitted; these actions must be documented and verifiable. (required)
If you selected "Yes" above, upload supporting documentation.

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Have you ever been dismissed or expelled from a radiologic science program?*

YesNo
If you selected "Yes" above, describe what actions you have taken to ensure success if admitted; these actions must be documented and verifiable. (required)
If you selected "Yes" above, upload supporting documentation.

PDF files only
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Being dismissed or expelled from a Radiologic Science Program due to serious honor code (academic) violations as described in the ARRT's Standards of Ethics may require you to request an ethics review from the ARRT. Serious honor code (academic) violations include, but are not limited to, patient abuse, violating patient confidentiality, and cheating. Failing grades or falling asleep in class are not considered serious honor code (academic) violations and do not require you to request an ethics review from the ARRT.

If you have been dismissed due to a serious honor code (academic) violation, you must request an ethics review. For questions about honor code violations, contact the DMI Program Director, William Morgan, at wmorgan@ccsf.edu.

Steps for Requesting an Ethics Review
1. Ethics Review Preapplication - ARRT
2. Call (651) 687-0048 ext. 8580
You may submit an application while the ARRT ethics investigation is ongoing.

Additional Requirements
Health Care Facility Employment History
“Health care facility” means any of the following:
- A general acute care hospital as defined in subdivision (a) of Section 1250 of the Health and Safety Code.
- An acute psychiatric hospital as defined in subdivision (b) of Section 1250 of the Health and Safety Code.
- A skilled nursing facility as defined in subdivision (c) of Section 1250 of the Health and Safety Code.
- A clinic organized under subdivision (l) of Section 1206 of the Health and Safety Code that is affiliated, owned, or controlled by a person or entity that owns or operates a facility described in subparagraph (A).
- A clinic organized under subdivision (b), (d), or (r) of Section 1206 of the Health and Safety Code that is affiliated, owned, or controlled by a person or entity that owns or operates a facility described in subparagraph (A) or Parts 405 and 491 of Title 42 of the United States Code.
- A physician organization that is part of a fully integrated delivery system that includes a physician organization, health facility or health system, and a nonprofit health care service plan that provides medical services to enrollees in a specific geographic region of the state through an affiliate hospital system and an exclusive contract between the nonprofit health care service plan and a single physician organization in each geographic region to provide those medical services.
- A designated public hospital system that is comprised of a designated public hospital, as defined in subdivision (f) of Section 14184.10 of the Welfare and Institutions Code, and its affiliated governmental health and behavioral health provider entities, including nonhospital settings. A single designated public hospital system may include multiple designated public hospitals under common government ownership.
Do you have paid employment history with a health care facility for one year or more (health care facility employment history is not a considering factor when reviewing your application)?

YesNo
Physical, Mental, and Emotional Aptitude for Radiologic Technologists

The Physical, Mental, and Emotional Aptitude for Radiologic Technologists can be found here under the accordion titled "Physical, Mental, and Emotional Aptitude for Radiologic Technologists."
The student radiologic technologist must be capable of meeting all physical, mental, and emotional requirements of the radiologic technology profession.*

Yes, I have read and understand the criteria as outlined in the Physical, Mental, and Emotional Aptitude Requirements for Radiologic Technologists.
Physical Exam, Vaccine Proof, Immunization Proof, Background Check, and Drug Screen

If accepted into the DMI program, the following requirements must be met:
- Physical examination by a physician to determine a student meets the physical, mental, and emotional aptitude requirements for a radiologic technologist
- Vaccination proof of Tdap, seasonal influenza (flu), and Tuberculin test
- Immunization proof of COVID-19, Rubeola, Rubella, Mumps, Varicella, and Hepatitis B
- Negative background check
- Negative drug screen
The student radiologic technologist must meet physical examination, vaccine proof, immunization proof, background check, and drug screen requirements.*

Yes, I acknowledge I will be required to meet physical examination, vaccine proof, immunization proof, background check, and drug screen requirements.
Felonies or Misdemeanors

Felony and misdemeanor convictions, regardless of resolution, may cause an applicant to be ineligible to take the national certification examination given by the American Registry of Radiologic Technologists (ARRT). All hospitals accredited by The Joint Commission require radiographers to be certified by the ARRT.

If an applicant has a felony or misdemeanor conviction, the ARRT must determine eligibility for the Registry examination before the applicant has completed the program. It is the responsibility of the applicant to pursue this matter. The program is not and will not be involved in this process in any manner. The ARRT will consider, for determination of eligibility, any felony or misdemeanor conviction of an applicant on a case-by-case basis. The ARRT charges a fee for this service.
Have you ever been convicted of a felony or misdemeanor (felony or misdemeanor convictions are not a considering factor when reviewing your application)?*

YesNo
If you selected "Yes" above, you must request an ethics review through the ARRT.

I will request, or have requested, an ethics review through the ARRT. I also understand I may submit this application while the ARRT ethics investigation is ongoing.
Steps for Requesting an Ethics Review
1. Ethics Review Preapplication - ARRT
2. Call (651) 687-0048 ext. 8580
Miscellaneous Supporting Documents (optional)

Upload any miscellaneous supporting documents such as e-mail correspondence. Do not upload personal statements or letters of recommendation.
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Equal Opportunity Statement & JRCERT Standards
Equal Opportunity Statement

The Radiologic Sciences Department is committed to providing a workplace and an educational environment free of discrimination, harassment, intimidation, threats, or coercion based on a legally protected status. Therefore it is the policy of the Radiologic Sciences Department to provide all persons with equal educational opportunities in all of its programs and activities regardless of race, color, national origin, ancestry, ethnic group identification, religion, age, gender, marital status, domestic partner status, sexual orientation, disability or AIDS/HIV status, medical conditions, gender identity, or status as a Vietnam-Era veteran. This will include anyone perceived as having these characteristics or associated with anyone having these characteristics.

Further, the Radiologic Sciences Department does not tolerate retaliation against any employee or student for making a valid complaint or charges under the provisions of its nondiscrimination procedures, or for cooperating in an investigation. The Radiologic Sciences Department complies with all applicable laws, including Titles VI and VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, Sections 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, Title IX of the Education Amendments of 1972, California Government Code Section 11135 et. seq. and all applicable regulations, and with all applicable requirements related to receipt of federal and/or state funds.

Information concerning the provisions of the applicable laws and complaint procedures is available from the District Title 5/EEO/ADA/Title IX Compliance Officer. The compliance officer/coordinator for purposes of this policy is the District Title 5/EEO/ADA/Title IX Compliance Officer, 50 Frida Kahlo Way, B213, San Francisco, CA 94112, (415) 452-5053.
JRCERT Standards
The Joint Review Committee on Education in Radiologic Technology (JRCERT) Standards for an Accredited Educational Program in Radiography are designed to promote academic excellence, patient safety, and quality healthcare. The Standards require a program to articulate its purposes; to demonstrate that it has adequate human, physical, and financial resources effectively organized for the accomplishment of its purposes; to document its effectiveness in accomplishing these purposes; and to provide assurance that it can continue to meet accreditation standards. Detailed information about the standards can be found on the JRCERT website www.jrcert.com.
- Standard 1: Accountability, Fair Practices, and Public Information
- Standard 2: Institutional Commitment and Resources
- Standard 3: Faculty and Staff
- Standard 4: Curriculum and Academic Practices
- Standard 5: Health and Safety
- Standard 6: Programmatic Effectiveness and Assessment: Using Data for Sustained Improvement

Signature, Save, and Submit
To the best of my knowledge, the information contained in this application is a true and correct representation of my qualifications. I acknowledge: (select all)*

Any missing information is cause for disqualification.No edits or additions (including attaching transcripts/documents) can be made to the application once submitted.Only one application is allowed per person per application cycle. Multiple submissions will disqualify the applicant.
Signature*

Clear

ATTENTION

Clicking "Save" Does NOT Submit Your Application

To officially submit your application, you must click "Submit" between July 10 and August 15. The submit button will only be available between July 10 and August 15. Clicking "Save" does not submit your application. Clicking "Save" will save your progress so you can return between July 10 and August 15 to officially submit your application.

After clicking Submit, you will receive a submission confirmation email. If you do not receive a submission email within two hours, contact DMI@ccsf.edu.

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