Radiography Program - Clinical Observation Verification Statement
Applicant's Name ___________________________________
Observation Date ___________________________________
Number of HRS. observed ___________________________
List some of the radiographic examinations that you observed;
- __________________________________________
- __________________________________________
- __________________________________________
- __________________________________________
- __________________________________________
- __________________________________________
What did you like about your clinical observation?
________________________________________________________________
________________________________________________________________
What did you dislike about your clinical observation?
________________________________________________________________
________________________________________________________________
Signature of Applicant ___________________________________________
Signature of Staff Technologist(s) _________________________________________
Four hours of observation time is a requirement of the ECTC Radiography Program. This
form is part of the application process. You are requested to complete this form at
the time
of your observation and return it to the Radiography Program Director for your
application to be completed.
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