OREGON INSTITUTE OF TECHNOLOGY Medical Imaging Technology Program (MIT) STATEMENT OF COMPREHENSION FOR THE MIT PROGRAMS SELECTION PROCESS

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1 OREGON INSTITUTE OF TECHNOLOGY Medical Imaging Technology Program (MIT) STATEMENT OF COMPREHENSION FOR THE MIT PROGRAMS SELECTION PROCESS Student Name (printed): My signature below signifies that I have read and understand the following. Upon my completion of the Pre-MIT year and consideration for entry into one of the five programs offered, I will be in accordance with the selection process outlined at (click on Selection Criteria and Application Information). I understand there is a $75.00 Application Fee due upon submittal of my application to one of the five programs payable to OIT/MIT. I am fully aware that the number of individuals selected for the program is dependent upon the number of faculty and lab space available. I understand my acceptance into a program is contingent on meeting the OIT/MIT Physical Standards, as listed in the MIT Technical Standards. I have been informed that upon acceptance I must also submit a Background Check, and must pass a drug screen. Both the OIT/MIT physical, and drug screen, will be conducted at a local facility chosen by the MIT department. Background Check instructions are located at click on Selection Criteria, then Background Checks. I understand there is a fee for the Background Check which must be paid online. There are also fees for the drug screen and physical. I understand that I may also be required to pass an additional drug screen and another background check prior to the Extern portion of the program. These pre-externship requirements are externship site-specific, and as such may vary in terms of the extent of the background check or drug screen, and in terms of where and how they are administered. I also acknowledge that I am responsible for reading all of the information, adhering to the rules, policies and guidelines listed on the MIT website. Student s Signature Date

2 MEDICAL IMAGING TECHNOLOGY PROGRAMS Student Name (printed): Date: My signature below is given as evidence that I am fully aware the Medical Imaging Technology Program of the Oregon Institute of Technology will, upon completion of the required curriculum as stated in the OIT catalog, guarantee my placement in an extern facility. I further understand: 1. The specific location of the externship is NOT guaranteed. 2. I am only guaranteed one extern site by the Oregon Tech MIT program. 3. There is no guarantee of a stipend. 4. Malpractice insurance is required. This fee is automatically charged when I register for any MIT 103 course and in specified courses each term once in the program. 5. If I refuse my externship selection, this will relieve OIT from any further responsibility of placement. 6. Externship placement is to begin, approximately, on July 1 of each year. 7. I am to maintain strict confidentiality of all medical records. 8. If I have a physical disability, an externship will not be assigned until a physician s release for return to work is obtained by OIT. It is my responsibility to inform the Program Director of any possible disability, either current or acquired, during completion of the academic portion of the program. 9. I understand that I will be required to pay regular tuition during externship. Student Signature Date

3 DISCLOSURE STATEMENT According to the state bill CHAPTER 409 Division 30 Administrative requirements for Health Profession Student Clinical Training ( to ), Information must be verified before health professions program students may begin clinical placements, and includes criminal background checks, drug testing for substance abuse, health screenings, immunizations, and basic training standards. Please answer the following truthfully. Have you ever been charged or convicted for any of the following crimes? Charged/Arrested Convicted YES NO YES NO Murder (Aggravated, First or Second Degree) Kidnapping (First or Second Degree) Assault (First, Second, or Third Degree) Rape (First, Second, or Third Degree) Statutory Rape (First, Second, or Third Degree) Robbery (First or Second Degree) Arson (First Degree) Burglary (First Degree) Manslaughter (First or Second Degree) Extortion (First or Second Degree) Indecent Liberties Incest Vehicular Homicide First Degree Promoting Prostitution Communication with a Minor

4 Have you ever been charged or convicted for any of the following crimes? Charged/Arrested Convicted YES NO YES NO Unlawful Imprisonment Simple Assault Sexual Exploitation of a Minor Criminal Mistreatment (First or Second Degree) DUI Controlled Substance Possession Sale/Distribution If your answer was Yes to any of the above, or you were charged with something other than those listed above, please provide date(s) of the arrests/charges or convictions and sentence(s). IF you answered YES to any of the above, it is HIGHLY recommended you complete the ARRT or ARDMS Eligibility form (Located online at or ) prior to entering the program (or) sitting for the certification exam.

5 Felony or Misdemeanor: If I meet any of the following, it is HIGHLY recommended that I complete the ARRT or ARDMS Pre-Application eligibility form prior to entering the program (or) sitting for the certification exam. (Located online at or ). a. A charge or conviction of, a plea of guilty to, or a plea of nolo contendere (no contest) to an offense that is classified as a misdemeanor or felony constitutes a conviction for ARRT/ARDMS purposes. b. A conviction that results in withheld adjudication or a suspended sentence must be reported. c. Misdemeanor convictions related to alcohol or drug use. NOTE: Misdemeanor speeding convictions are not required to be reported unless they are related to alcohol or drug use. Convictions previously reported to ARRT/ARDMS and which have been formally cleared as evidenced by a letter from ARRT/ARDMS to that effect should be indicated as NO below. Contact ARRT/ARDMS if you have any questions about reporting requirements. Yes, I meet one or more of the above convictions. No, I have not been charged with a misdemeanor or felony. The certification body and/or externship facility may request a report of criminal convictions for offenses against a person, civil adjudications or child abuse, and disciplinary board final decision. If you are placed before that report is available, YOUR EXTERNSHIP WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT. UNDER PENALTY OF PERJURY, I certify that the above information is true, correct, and complete. I understand that if I am placed, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am placed, my externship is dependent on your receipt of a satisfactory report. Signature Date Print Your Name

6 On this date, I fully understand that: MEDICAL IMAGING TECHNOLOGY PROGRAMS 1. I must complete questionnaires that are required by Oregon, Washington, or any other state that requires me to reveal facts pertinent to my personal legal history. This information may result in my being rejected by a clinical site and that Oregon Tech will NOT be obligated in any way to find me another clinical site. 2. I may be required to pass a drug test before being accepted by a clinical site. If the test is positive and I am rejected by the clinical site, I understand that Oregon Tech will NOT be obligated in any way to find me another clinical site. 3. Attendance of classes or labs under the influence of drugs or alcohol is prohibited, and may result in dismissal from the program. 4. I must carry Health Insurance while attending OIT, and must work these details out with the Student Health Center. Print Name Signature