Approved: Part 1__________ Part 2___________ AMP/RSO/None__________
FOR OFFICE
USE ONLY Approval Signature _____________________________________________
Approval Signature _____________________________________________
Date Received: Registration Number:
8/2010
Radiologic Physics
Registration for Initial Certification
Use this registration form ONLY if you are a medical physicist applying for certification in radiologic
physics. One form takes you through the entire examination process. You will be requested to update
your file periodically on forms provided by the ABR. Do not file any subsequent registration forms unless
the ABR instructs you to do so. Candidates who submit registrations to the ABR will be initially reviewed
for Part 1 only. Once a candidate takes and passes Part 1, the ABR will then collect documentation for
Part 2 exam eligibility review. You will NOT be reviewed for Part 2 until you pass Part 1.
Make 2 copies of this form. Use extra paper for additional data if necessary.
TYPE IN OR PRINT CLEARLY (IN INK) ALL INFORMATION
Please indicate the subfield in which you are registering for certification. If you are registering for more than one
certification, you must file a separate registration form for each.
Therapeutic Radiologic Physics
Diagnostic Radiologic Physics
Medical Nuclear Physics
1.) CONTACT INFORMATION
Any change in contact information must be reported to the ABR immediately.
Name: ____________________________________________________________________ Male Female
Last name First name Middle name
Address to which you want Board correspondence sent:
________________________________________________________________________________________________________
Street Address
____________________________________________________________________________________
City State Zip
Last 4 Digits of your Social Security Number (U.S. or Canadian): _________________________________________
Date of Birth: ____________________ Birthplace: ___________________________________________________
MM / DD / YYYY City State Country
Citizenship: __________________________________________________________________________________
Country
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Telephone Numbers: Office: Fax:
Home: ________________________________ Fax: _______________________________
E-mail Address: _______________________________________________________________________________
Have you previously been certified by the ABR?
Yes (If yes, no fee is due at this time.) Do not complete any other section, and make a note on the front of your
submission packet that you are registering for multiple disciplines.
If yes, in what field? _________________________________________________________________
No (If no, the registration fee must be included with this form. See web site for fee information.)
Review the requirements on the ABR web site (http://www.theabr.org/ic/ic_rp/ic_rp_req.html) before
you complete this form. Use this web site as a resource when completing your registration.
2.) EDUCATION*
LIST all undergraduate and graduate degrees.
PROVIDE OFFICIAL TRANSCRIPTS for all undergraduate and graduate degrees.
Academic School, City, & State CAMPEP?** Major Minor Date Completed
Degree (Y/N) MM / YYYY
2a.) If you are currently enrolled in a CAMPEP-accredited graduate program, please enter the following
information, and PROVIDE OFFICIAL TRANSCRIPT.
School, City, & State Major Minor Expected Completion Date
* International Medical Graduates holding only non-United States (U.S.) degrees MUST provide documentation
that their foreign degrees are equivalent to those granted from an approved institution in the U.S. Please go to
ABR-approved list at http://www.theabr.org/ic/ic_int/ic_int_rp_orgs.html to view the credential organizations list
and instructions. No credentialing institutions other than those listed on the ABR web site will be accepted.
** Is this a CAMPEP-accredited graduate program? Answer yes (Y) or no (N).
Ensure the institution appears on the list of accredited programs on the CAMPEP web site: www.campep.org.
3.) CAMPEP RESIDENCY INFORMATION
Are you are enrolled in a CAMPEP-accredited residency program?
YES NO
If YES, complete this section and continue on to the next section. If NO, go directly to section 4.
Institution, City, State Entry Date
(MM/YYYY)
4.) MEDICAL PHYSICS REQUIREMENTS
If you are NOT in or have NOT graduated from a medical physics graduate program (CAMPEP accredited or
non-CAMPEP accredited), complete this section and continue to the next section. Otherwise, go directly to
the next section (5).
LIST specific medical physics courses you have completed (minimum of three).
PROVIDE OFFICIAL TRANSCRIPTS to verify completion.
Course Institution, City, State Date Completed
MM / YYYY
If your graduate thesis or dissertation was on a medical physics topic, provide the title and date completed:
Title:_______________________________________________________________________Date: _____________
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5.) BIOLOGICAL SCIENCES REQUIREMENTS
If your degree is NOT from a CAMPEP-approved graduate or residency program, complete this section and
continue to the next section. Otherwise, go directly to section 6.
LIST specific biological sciences courses you have completed. These must include a minimum of 2
courses; for example:
one in biology or radiation biology, and
one in anatomy or physiology.
PROVIDE OFFICIAL TRANSCRIPTS to verify completion.
Course Institution, City, State Date Completed
MM / YYYY
6.) NON-PHYSICS DEGREE REQUIREMENTS
If your undergraduate/graduate degree is NOT in physics or applied physics, other physical science or
engineering degrees may be considered if the appropriate fundamental physics courses have been completed
equivalent to a minor in physics (including general physics with calculus and a minimum of three upper level
courses in, for example, electricity and magnetism, atomic physics, nuclear physics, modern physics, quantum
mechanics, and/or mechanics).
If you feel the courses you have taken in your non-physics graduate program are equivalent to any upper-level
physics courses such as those listed above, it is your responsibility to document equivalence by providing
course descriptions as found in official catalogs from your educational institution, or other detailed syllabi as
provided by the course instructors.
LIST specific physics courses you have completed.
PROVIDE OFFICIAL TRANSCRIPTS to verify completion.
Course Institution, City, State Date Completed
MM / YYYY
PLEASE READ CAREFULLY BEFORE SIGNING
I, the undersigned, hereby register with the American Board of Radiology, Inc. for examination leading to certification, in
accordance with and subject to stated rules and regulations. I agree to disqualification from examination or from issuance of a
certificate of qualification in the event that any of the statements herein made by me are false, or if I violate any of the rules
governing such examination.
I recognize the trustees of the American Board of Radiology (hereinafter, the Board) as the sole and only judge of my
qualifications to receive and to retain a certificate issued by the Board and to have my name and demographic data included in
any list or directory in which the names of diplomates of the specialty boards are published. I understand and agree that in the
consideration of my registration, my moral, ethical and professional standing will be reviewed and assessed by the Board; that
the Board may make inquiry of the persons named in my registration form and of such other persons as the Board deems
appropriate with respect to my moral, ethical and professional standing; that if information is received which would adversely
affect my registration, I will be so advised and given an opportunity to rebut such allegations, but I will not be advised as to the
identity of any individual who has furnished adverse information concerning me; and that all statements and other information
furnished to the Board in connection with such inquiry shall be confidential, and not subject to examination by me or by anyone
acting on my behalf. I also pledge myself to the highest ethical standards in the practice of radiology.
I accept that admissibility to all certifying examinations is determined by the executive committee of the Board, and that each
examination will be supervised by proctors who are responsible to the Board and empowered by the Board to ensure that the
examination is conducted ethically and in accordance with the rules of the Board. I understand that I must bring government-
issued photo identification to any examination that I attend. Such identification includes one of the following: state-issued driver’s
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license, military ID, passport, state-issued ID. I further understand that no beeper, recorder, camera, PDA, cellular phone, or any
device that has the capability to record pictures, text, or sound can be brought to the examination; and that I am not permitted to
bring into the examination any notes, scratch paper, textbooks, calculators or other reference materials. I further understand that
irregular behavior such as copying answers, sharing information, using notes, or otherwise giving or obtaining unauthorized
information or aid—evidenced by observation, statistical analysis of answers, or otherwise—on any portion of the examination
will be reported to the Board and will constitute grounds for the invalidation of my examination, and may lead to my being judged
unacceptable for certification by the Board. I recognize that examination materials, examination questions, props for the oral
examination, and questions on the oral examination are copyrighted as the sole property of the American Board of Radiology
and must not be removed from the test area or reproduced, in whole or in part, and that any reproduction of copyrighted material
is a federal offense.
In furtherance to my registration with the American Board of Radiology, I hereby request and authorize any hospital or medical
organization of which I am a member, have been a member, or to which I have applied for membership, and any person who
may have information which is deemed by the Board to be material to its evaluation of my registration, to provide such
information to representatives of the Board upon their request. I agree that communication of any nature made to the Board
regarding my registration may be made in confidence and shall not be made available to me under any circumstances. I hereby
release from liability any hospital, medical staff, medical organization or person, and the Board and its representatives, from
liability for acts performed in good faith and without malice in connection with the provision, collection, or evaluation of
information or opinions, whether or not requested or solicited by the Board in connection with my registration. I understand and
agree that as a registrant, I have the responsibility to supply the Board with information adequate for the Board’s proper
evaluation of my credentials. I further agree that I will not cause or attempt to cause any public disclosure of the contents of any
registration form, including my own, or any proceedings of any committee’s evaluation of such registration form, whether such
disclosure is by operation of law or otherwise.
I waive and release and shall indemnify the Board and its directors, members, officers, committee members, employees, and
agents from, against and with respect to any and all claims, losses, costs, expenses, damages, and judgments (including
reasonable attorney’s fees) alleged to have arisen from, out of, with respect to or in connection with any action which they, or
any of them, take or fail to take as a result of or in connection with this registration, any examination conducted by the Board
which I register to take or take, the grade or grades given me on an examination and, if applicable, the failure of the Board to
issue me a certificate or qualification or the Board’s revocation of any certificate or qualification previously issued to me.
To help analyze the effectiveness of my training program, I hereby authorize the American Board of Radiology to release to the
director(s) of the program in which I am or was enrolled, and to the chair of the department of which the program is a part, the
results of my performance on the examinations conducted by the American Board of Radiology.
Signature Date
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7.) CHECKLIST FOR SUBMISSION
□ Register according to the following schedule:
July 1: Registration opens
Initial (Standard) Registration Process Timeline
Sept. 30: Deadline of submission of complete registration packets to the ABR. Packets received after this date
that do not qualify for the special circumstances timeline described below will be returned unopened with the
next opportunity for submission being in July 2011 for the 2012 written examinations under the requirements in
place for the 2012 examinations.
Oct. 31: ABR notification of acceptance/denial of registration packet - incomplete packets will be returned to
the candidate for resubmission with the requested documents or materials.
Nov. 20: Deadline of resubmission of completed packet for those previously returned for reasons of missing
documents or materials. Packets received after this date will be reviewed during the Secondary timeline (see
dates below).
Jan. 31: First notification of exam eligibility – Denied registrants are given 1 opportunity to appeal.
Feb. 28: Deadline for receipt of appeal
Mar. 20: Final notification of exam eligibility following review of appeal requests (only one appeal is allowed per
year)
Secondary (Special Circumstances) Registration Process Timeline
Available only for those candidates with required courses completed and/or degrees conferred between
September 30 and December 31.
Jan. 15: Deadline of submission of complete registration packets to the ABR
Jan. 31: ABR notification of acceptance/denial of registration packet - incomplete packets will be returned to
the candidate for resubmission with the requested documents or materials.
Feb. 20: Deadline of resubmission of completed packet for those previously returned for reasons of missing
documents or materials.
Feb. 28: Final ABR notification that registration is complete – Files will move on to eligibility review OR files will
be held until next year’s registration cycle.
Mar. 31: First notification of exam eligibility – Denied registrants are given 1 opportunity to appeal.
Apr. 30: Deadline for receipt of appeal
May 31: Final notification of exam eligibility following review of appeal requests (only one appeal is allowed per
year)
□ Two (2) signed copies of the registration form. Incomplete forms will be returned to you.
□ Official transcripts for all courses listed on this form in Sections 4, 5, and 6.
□ Official transcripts of your undergraduate and graduate degrees showing degree conferral (all documents must
be in English) as listed in Section 2. Official transcripts are considered to be an original document from the
institution. Photocopies of transcripts are not allowed.
o NACES evaluation is required if all degrees are non-U.S. Not required if one or more degrees
are completed in the U.S. Paperwork must be sent from organization directly to the ABR.
Are you currently enrolled in a CAMPEP-accredited program?
□ Yes - Submit transcript and letter of enrollment on institution letterhead signed by program director.
□ Submit payment in U.S. currency by personal check, money order, Visa, or MasterCard, payable to The
American Board of Radiology. Please see our web site, http://www.theabr.org/all/all_fees.html, for the
current fee schedule. If paying by credit card, please include the completed Credit Card Form on the following
page.
□ All documents must be submitted together with completed registration forms and payment to:
THE AMERICAN BOARD OF RADIOLOGY
5441 E. WILLIAMS BLVD., SUITE 200
TUCSON, ARIZONA 85711
Incomplete forms will not be accepted.
Once you have submitted your registration packet, do not contact the ABR until after the
acceptance/denial notification date listed above. The ABR will not respond to telephone or e-mail
requests regarding receipt of your registration packet prior to this date. If verification of receipt is
desired, packets should be sent with return receipt requests or using a company that employs a
tracking mechanism.
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CREDIT CARD FORM
Though you are making 2 copies of the registration form, only 1 credit card form is required.
Purpose of payment: Registration for Initial Certification – Radiologic Physics______________
Candidate name: __________________________________________________________________
Exact name that appears on credit card: ________________________________________________
The following information must be as it applies to billing of the credit card.
Billing address: ___________________________________________________________________
City: _________________________________ State: __________________ Zip Code: _________
Phone: _____________- ______________- __________________________
Visa □ MasterCard □
CC#: - - -
Expiration date: _____________________
Amount authorized: $____________________
Signature of card holder: ______________________________________________
If your payment is declined for any reason, there will be a $100.00 processing fee.
For office use only
ABR ID #: ______________________ Fee Code: ____________________
6-2010
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