SELF-STUDY AND

APPLICATION FOR ACCREDITATION

FOR

EDUCATIONAL PROGRAMS IN NUCLEAR MEDICINE TECHNOLOGY

EFFECTIVE 01/01/05

Please Return Original and 4 copies to:

Elaine J. Cuklanz, MS, MT(ASCP)NM Executive Director

Joint Review Committee on Educational Programs in Nuclear Medicine Technology

716 Black Point Road P.O. Box 1149

Polson MT 59860-1149

Telephone: 406.883.0003 Fax: 406.883.0022

Email: jrcnmt@centurytel.net www.jrcnmt.org

Name of person to whom correspondence should be sent:

TABLE OF CONTENTS

Section.......................................................................................................................................................................... Page Instructions for Completion of the Self-Study Report ............................................................................................................. i Data Form ............................................................................................................................................................................... 1 Program Information .............................................................................................................................................................. 6 Clinical Information ............................................................................................................................................................. 27 Self-Study Report.................................................................................................................................................................. 36 Authorized Signatures........................................................................................................................................................... 39 Program Information Checklist............................................................................................................................................. 41 Clinical Information Checklist.............................................................................................................................................. 49 Standard Forms A. Program Information Forms Curriculum vitae (Form A) .............................................................................................................................................. 18 Faculty Instructional Chart (Form B).............................................................................................................................. 19 Library Information (Form C)......................................................................................................................................... 20 Program Publications (Form D)...................................................................................................................................... 21 Student Capacity (Form E) ............................................................................................................................................. 22 Student Evaluation (Form F)........................................................................................................................................... 23 Master Clinical Rotation Schedule (Form G) ................................................................................................................. 25 Operation Policies (Form H)........................................................................................................................................... 26 B. Clinical Information Forms ................................................................................................................................................ Clinical Staff (Form CL-A)............................................................................................................................................. 28 Nuclear Medicine Equipment (Form CL-B) ................................................................................................................... 29 Nuclear Medicine Procedures List Imaging Procedures (Form CL-C1) ............................................................................................................................ 30 Non-imaging Procedures (Form CL-C2) .................................................................................................................... 31 Radiopharmaceuticals (Form CL-C3)......................................................................................................................... 31 License and Quality Assurance (Form CL-D) ................................................................................................................ 32 Student Capacity Worksheet (Form CL-E)..................................................................................................................... 32 Clinical Library (Form CL-F) ......................................................................................................................................... 33 External Quality Assurance (Form CL-G)...................................................................................................................... 34

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INSTRUCTIONS FOR COMPLETION

OF THE SELF-STUDY REPORT

PART I I. Introduction

This section should include a statement of how the self-study was conducted, the period of time devoted to the study, and a list of participants and their committee assignments. A brief historical overview of the program and description of the program's organization/structure is helpful to the self-study readers and site evaluators.

II. Data Form This form contains quantitative and factual data on the sponsoring institution that are common to allied health educational programs. The material requested is self-explanatory. For coordinated/concurrent visits, it may be completed once and duplicated for inclusion with the various programs' reports. It may be helpful to complete this form at the onset of the self-study process so that the committee can use the basic data it provides. Note: When identifying key individuals include credentials (such as Ph.D., Ed.D., etc.). Also verify that requested student capacity for each clinical affiliate is the same as indicated on Form CL-E.

III. Program Information Report This section contains quantitative and factual information on the nuclear medicine technology program being evaluated. Instructions for completion are on recommended form(s) when indicated. The program information report is organized to parallel each criterion of the Essentials and Guidelines for an Accredited Educational Program for the Nuclear Medicine Technologist. The Authorization to Conduct On-Site Evaluation (sponsoring institution) will be found as page 37 of the self-study document. This should be completed by the appropriate signatories and inserted as indicated in the report’s Table of Contents.

IV. Clinical Information Report This section contains quantitative and factual information on clinical institutions affiliated with the program. Instructions for completion are on the recommended form(s) when indicated. The clinical affiliate(s) should complete the clinical information portion at the onset of the self-study process so the committee can use this basic information. Use the legal name of the clinical affiliate at all times. If the clinical affiliate is not recognized by a national agency, the form External Quality Assurance for Clinical Affiliates of JRCNMT Accredited Programs must be completed. Radiopharmacies should submit the state pharmacy license. The Authorization to Conduct On-Site Evaluation (clinical facility) will be found as page 38 of the self-study document. This should be completed by the appropriate signatories and inserted as indicated in the report’s Table of Contents.

V. Self-Study Report Note that the Self-Study Report parallels that of the Essentials and Guidelines for an Accredited Educational Program for the Nuclear Medicine Technologist. The Self-Study Report should reflect the findings and conclusions resulting from the self-study process in relation to compliance with each Essential. It is to be a qualitative assessment of the strength and/or weakness of the program with respect to the criterion. It is not necessary to repeat data or information contained in the Data Form, Program Information Report, Clinical Information Report and the Appendices, unless it is absolutely essential for the sake of clarity. Descriptions of other current program elements should be kept to a minimum and generally used only where needed.

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INSTRUCTIONS FOR COMPLETION

OF THE SELF-STUDY REPORT

continued VI. Summary The summary is a statement of the significant findings from the overall self-study process including strengths and weaknesses and should also include a review of how the program has addressed any concerns cited during the previous accreditation review. If there are future plans to remedy any significant deficiencies these should be included. PART II Part II of the self-study report will contain the appendices. PART III. LIST OF MATERIALS TO BE AVAILABLE ON-SITE The following list of materials is to be available for the on-site survey: a) Student records b) Film badge reports c) Copy of certificate or degree awarded d) Recent exams e) QC/QA records as required by JCAHO f) Documentation of professional development of faculty g) Minutes of Advisory Committee Meetings (if applicable)

h) Certification scores of graduates i) Records of site visits by program director and/or clinical coordinator to the clinical affiliates

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INSTRUCTIONS FOR ASSEMBLING THE FINAL DOCUMENT 1. The Self-Study Report consists of two parts to be submitted in advance of the site evaluation visit. Part III is a list of

the materials to be available on-site for review by the site visit team. 2. The self-study report and all forms must be typewritten. Only signatures should be handwritten. 3. All curricula vitae (Form A) must include documentation of certification and board examinations. 4. The self-study report should be placed in a flat, report cover style binder. Each volume should not be more than 2”

thick. 5. The cover of the report should clearly identify the name of the institution, address of the institution, date submitted,

and an indication as to whether it is the original or a copy (the complete submittal must consist of an original and four copies). An example follows:

NAME OF INSTITUTION

ADDRESS

VOLUME

DATE SUBMITTED

ORIGINAL

(OR COPY 1 OF 4)

6. The Program Table of Contents must be completed and place in the front of the document. 7. All requested materials should be placed in the sequence listed in the Program Table of Contents. Exhibits or forms

for each Essential should be placed immediately behind the narrative portion. 8. If the program has multiple clinical affiliates, the Clinical Information Reports should be placed in a separate binder,

again not more than 2” thick. Additional binders should be used if the number of clinical affiliates cannot fit into one binder.

9. Major sections of the original and each of the four copies should be separated by tabs and clearly identified. The

clinical affiliates should be separated with the name of the affiliate institution identified on the tab. All pages are to be numbered.

10. Checklists for both the program and clinical affiliate(s) are included within the self-study materials. The Checklists

are designed with a two-fold purpose. The first will assist the institutional self-study team in reviewing the document for completeness. The second is to assist the Review Committee and on-site evaluator(s) in locating required information. Please enter the location of the required documentation as indicated and return with the Self-Study Report. Do not bind the checklist within the document. Please place the loose copy in front of each document. A checklist must be completed for each clinical affiliate and the loose copy(ies) inserted in the front of the binder containing the Clinical Information Reports.

It is imperative that the Table of Contents, Sequence of Documentation and Checklists be prepared as instructed.

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The Table of Contents will be the first page of the document. The location of each identified item should be indicated by completing the page number, tab number and/or volume number as appropriate of its location in the document. The final document should be assembled in the sequence listed in the Table of Contents. Note: An asterisk precedes items to be included under the Clinical Information Report. Assemble the asterisked items for each clinical affiliate as a separate set. A tab should divide each set.

NAME OF PROGRAM

TABLE OF CONTENTS

PART I Page No. in Self-Study

I. INTRODUCTION A. Self-study process .................................................................................................................... B. Overview of program ....................................................................................................................

II. DATA FORM .................................................................................................................... III. PROGRAM INFORMATION REPORT ESSENTIAL I –SPONSORSHIP (Statement of institutional mission and goals).......................................................

I.A. Sponsoring Institution 1. Statement of program mission and goals .............................................................................. 2. Copy of institutional accreditation document .......................................................................

I.B. Affiliated Institutions 1. Description of supervision, coordination and continuing communication ........................... 2. Minutes of the semi-annual meetings of Advisory Committee ............................................

I.B.1. Academic Affiliates 1. Description of the relationship of the academic affiliates and the sponsoring institution .... 2. Signed affiliation agreement between academic affiliate and sponsoring institution...........

I.B.2. *Clinical Affiliates I.B.3. *Clinical Affiliates-Categories I.C. Accreditation

ESSENTIAL II – RESOURCES (Description of instructor/student ration policy)..................................................... II.A. Human Resources

II.A.1 Program Director II.A.1.a. Responsibilities (Form A)........................................................................................ II.A.1.b. Qualifications (Form A)...........................................................................................

II.A.2. Clinical Coordinator II.A.2.a. Responsibilities (Form A)........................................................................................ II. A.2.b. Qualifications (Form A)...........................................................................................

II.A.3 Medical Director II.A.3.a. Responsibilities (Form A)........................................................................................ II.A.3.b. Qualifications (Form A)...........................................................................................

II.A.4. *Affiliate Clinical Coordinator II.A.5 *Affiliate Medical Director II.A.6. Faculty and/or Instructional Staff (Form B) ...................................................................................... II.B. Physical Resources .................................................................................................................... II.C. Financial Resources .................................................................................................................... II.D. Learning Resources II.D.1. Library (Form C) .................................................................................................................... II.D.2. Instructional Aids (On Site)

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TABLE OF CONTENTS-Continued

ESSENTIAL III - STUDENTS III.A Program Description (Form D) .................................................................................................................... III.B Admission Policies and Procedures (Form D) ................................................................................................

III.B.1. Admission Requirements (Form D)................................................................................................... III.B.2. Student Capacity (Form E) ................................................................................................................

III.C Student Rights and Responsibilities III.C.1. Dismissal (Form D) .................................................................................................................... III.C.2. Appeal Procedures (Form D) .............................................................................................................

III.D. Evaluation Criteria (Form F, pages 1 and 2)................................................................................................... III. E. Health 1. Published health policies.................................................................................................................... 2. Sponsoring institution radioactive materials license.......................................................................... 3. Quarterly reviews of radiation exposure records .............................................................................. III.F. Guidance ....................................................................................................................

ESSENTIAL IV - CURRICULUM IV.A. Description of the Program

1. Master Instructional Plan IV.B. Instructional Plan ....................................................................................................................

IV.B.1. Learning Opportunities .................................................................................................................... IV.B.2. Education in health and basic sciences - …....................................................................................... IV.B.2.a. Prerequisite Education .................................................................................................................... IV.B.3. Academic instruction for the professional nuclear medicine technology curriculum........................ IV.B.4. Supervised clinical education (Form G) ............................................................................................

ESSENTIAL V - OPERATIONAL POLICIES........................................................................................................... V.A. Fair Practices (Form H to include):.................................................................................................................

V.A.1. Announcements and advertising V.A.2. Student and faculty recruitment, student admission, faculty employment V.A.3. Academic credit and costs V.A.4. Grievance policy V.A.5. Non-routine clinical assignments V.A.6. Withdrawal policy and refund policy V.A.7. Student work policies V.A.8. Health and Safety Policies

V.B. Student Records (Form H to include) .............................................................................................................

a. Admission b. Attendance c. Evaluation d. Transcripts e. Radiation Exposure Records

ESSENTIAL VI - PROGRAM EVALUATION ......................................................................................................... VI. Effectiveness .................................................................................................................... VI.A.1. Outcomes .................................................................................................................... VI.C. Results of Ongoing Program Evaluation ........................................................................................................ ESSENTIAL VII. A SPONSORING INSTITUTION, PROGRAM AND JRCNMT RESPONSIBILITIES VII.A.1. Sponsoring institution - Authorization to Conduct Site Evaluation ..............................................................

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TABLE OF CONTENTS-Continued .................................................................................................. Tab/Page # IV . CLINICAL INFORMATION REPORT .................................................................................................... Information for each clinical should be assembled under a separate tab and include the following information in the order indicated: CLINICAL DATA FORM – Cover Page ................................................................................................................... ESSENTIAL I - SPONSORSHIP I.A. Signed affiliation agreement .................................................................................................................... I.B Identification and responsibilities of the representative to Advisory Committee ........................................... I.B.2. Clinical Affiliates

1. Description of role/relationship of clinical affiliate within the overall program. .............................. 2. Copy of the accreditation document or extramural quality assurance (Form CL-G) of the clinical facility.

ESSENTIAL II – HUMAN RESOURCES II.A.2. Affiliate (Form CL-A) .................................................................................................................... II.A.4 Affiliate Clinical Coordinator

II.A.4.a. Responsibilities (Form A)..................................................................................................... II.A.4.b Qualifications (Form A)........................................................................................................

II.A.5. Affiliate Medical Director II.A.5.a. Responsibilities (Form A)..................................................................................................... II.A.5.b. Qualifications (Form A)........................................................................................................

II.A.6. Faculty and/or Instructional Staff (Form CL-A) II.B. Physical Resources

1. Nuclear Medicine Equipment; Imaging and Non-Imaging (Form CL-B) ......................................... 2. Nuclear Medicine Procedures: Imaging/Non-Imaging/Pharmaceutical (Form CL-C) ...................... 3. Licensure and Quality Assurance (Form CL-D)................................................................................

II.D.1. Library (Form CL-F) .................................................................................................................... ESSENTIAL III – STUDENTS III.B.2. Student Capacity (Form CL-E) .................................................................................................................... ESSENTIAL IV – CURRICULUM

1. Master Clinical Rotation Schedule .................................................................................................... 2. Clinical Objectives and performance criteria for competencies to be learned at this facility............

ESSENTIAL VII. A SPONSORING INSTITUTION, PROGRAM AND JRCNMT RESPONSIBILITIES VII.A.2.d – Clinical Facility - Authorization to Conduct Site Evaluation-.................................................................. V. SELF-STUDY REPORT (NARRATIVE)...................................................................................................... VI. SUMMARY .................................................................................................................... PART II - APPENDICES A. Student Handbook ....................................................................................................................

B. College Catalog .................................................................................................................... C. Recruitment materials ....................................................................................................................

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SELF-STUDY REPORT

DATA FORM

A. SPONSORING INSTITUTION 1. Official Name of Sponsoring Institution Address City State & Zip 2. Type of Institution [ ] Academic Health Center/Medical School [ ] Four-year College or University [ ] Two-year College [ ] Vocational or Technical School [ ] Hospital or Medical Center [ ] Non-hospital Medical facility (laboratory) [ ] Department of Veterans Affairs [ ] U.S. Department of Defense 3. Nature of Institution: [ ] Public; [ ] Private, not-for-profit; [ ] Private, for-profit 4. Institutional Accreditation Regional Association Name Date ____/_____/_____ JCAHO Date ____/_____/_____ Other Date ____/_____/_____ 5. Is the sponsoring institution legally authorized under applicable state law to provide postsecondary education? [ ] Yes [ ] No [ ] No applicable state law 6. Has the institution or any other program received an adverse accreditation award from a regional or specialized

accreditor? [ ] Yes [ ] No [ ] Which accreditation agency? 7. Official student records are maintained [ ] permanently [ ] other duration (specify)

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B. Official Name of Program (if different than information for sponsoring institution) Name

Address

City _ State & Zip

1. Specify the following: a. Length of professional program, clinical and didactic:

in months

in contact hours

b. Number of classes admitted per year

c. Month(s) in which classes begin

d. Current approved clinical student capacity

e. Requested clinical student capacity

f. Award Granted: Diploma ( ) Certificate ( )

Degree ( ) Specify

g. Tuition and fees: Resident

Non-Resident

Stipend: Yes No

h. Entrance Requirements

2. Chief Administrative Officer of Sponsoring Institution Name Administrative Title Address City State & Zip 3. Dean or Coordinator of Allied Health Education (if applicable) Name Administrative Title Address City State & Zip Telephone (_____) FAX # (_____)

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C. AFFILIATED INSTITUTIONS 1) ACADEMIC Affiliated Institutions Address City, State, Zip Telephone (____) Accredited By Date Chief Executive Officer Nuclear Medicine Advisor Affiliated Institutions Address City, State, Zip Telephone (____) Accredited By Date Chief Executive Officer Nuclear Medicine Advisor Affiliated Institutions Address City, State, Zip Telephone (____) Accredited By Date Chief Executive Officer Nuclear Medicine Advisor Affiliated Institutions Address City, State, Zip Telephone (____) Accredited By Date Chief Executive Officer Nuclear Medicine Advisor NOTE: If more than four academic institutions are involved, duplicate and insert immediately after this page. Please number each affiliate.

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2) CLINICAL Affiliated Institution Address City, State, Zip Telephone (____) Accredited By Date **Shared Affiliate *Requested Student Capacity Maximum Student Capacity Distance (miles) to Sponsor Affiliate Medical Director Affiliate Clinical Supervisor Chief Executive Officer Affiliated Institution Address City, State, Zip Telephone (____) Accredited By Date **Shared Affiliate *Requested Student Capacity Maximum Student Capacity Distance (miles) to Sponsor Affiliate Medical Director Affiliate Clinical Supervisor Chief Executive Officer Affiliated Institution Address City, State, Zip Telephone (____) Accredited By Date **Shared Affiliate *Requested Student Capacity Maximum Student Capacity Distance (miles) to Sponsor Affiliate Medical Director Affiliate Clinical Supervisor Chief Executive Officer NOTE: 1) If more than three clinical institutions are involved, duplicate and insert immediately after this page. Please number each affiliate. 2) Complete a Clinical Information Report for each clinical affiliate. An asterisk precedes items in the Self-study to be included in the Clinical Data Form. * Identify the requested student capacity per agreement with the clinical education center and identify the maximum student capacity at each institution calculated on Form CL-E. ** When the clinical affiliate is shared with other educational program(s) please indicate. Identify number of student positions allotted to other programs.

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D. PROGRAM PERSONNEL 1. Program Director Name Administrative Title Address City State & Zip Telephone (___) Fax ( ) Email 2. Clinical Coordinator Name Administrative Title Address City State & Zip Telephone (___) Fax ( ) Email 3. Medical Director Name Administrative Title Address City State & Zip Telephone (___) Fax ( ) Email 4. Co-Medical Director Name Administrative Title Address City State & Zip Telephone (___) Fax ( ) Email

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SELF-STUDY - PROGRAM INFORMATION REPORT ESSENTIAL I SPONSORSHIP The nuclear medicine technology program shall be conducted in an institution that has documented its commitment to quality, integrity and performance. Documentation: Describe the mission and goals of the sponsoring institution. Reference the appropriate page in the institutional catalog. I.A Sponsoring Institution The sponsoring institution and affiliates must be able to provide resources needed to fulfill the mission and educational goals of the program and must be accredited by nationally recognized education accrediting agencies. Educational programs shall be located in: 1. colleges and universities, 2. community and junior colleges, 3. nuclear medicine laboratories, 4. hospitals and medical centers, 5. medical schools, 6. postsecondary vocational technical schools and institutions, and 7. other institutions or consortia which meet comparable standards for education in nuclear medicine technology. Documentation: Describe the mission and goals of the nuclear medicine technology program. Reference the appropriate page in the institutional catalog. Provide a copy of the accreditation document of the sponsoring institution and any academic affiliates. (Certificate and/or letter of accreditation) *Provide a copy of the accreditation document(s) of the clinical affiliate(s) with the clinical information report. I.B Affiliated Institution(s) Affiliated institutions shall be located in geographic locations that allow the sponsoring institution to maintain direct supervision, coordination and continuing communication to ensure that students enrolled receive uniform and adequate instruction and clinical experience. There shall be documented, ongoing communication between the institution and its affiliates for review of the program and its operation. Meetings shall be held at least semi-annually, one of which must be in the form of a formal meeting. Whenever an alternative to a formal meeting is employed, the methodology must be fully described and available for review. Meetings conducted by an alternative methodology must document how program goals and operations were reviewed and the interactive nature of the process. Each affiliated institution and the sponsoring institution shall appoint a representative from the nuclear medicine technology faculty to attend such meetings. Documentation: Describe how the sponsoring institution fulfills the described responsibilities. Provide minutes of the semi-annual meetings of the representatives of the sponsoring institution and the affiliates that document review of the program and its operations. The minutes should reflect members in attendance.

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I.B.1 Academic Facilities The program has the responsibility for ensuring that prerequisites are met. Where academic affiliates provide the prerequisites and/or award credit for the professional curriculum the responsibilities shall be clearly described in written agreements. Documentation: Describe the responsibilities of the academic affiliate. Provide a copy of the signed affiliation agreement between the sponsor and the academic affiliate. I.B.2 Clinical Facilities The clinical component of the program shall provide an environment for supervised competency-based clinical education and experience and offer a sufficient and well-balanced variety of nuclear medicine procedures, examinations and equipment. Modern nuclear medicine equipment, accurately calibrated, in working order and meeting applicable national and state standards must be available for the full range of diagnostic and therapeutic procedures as outlined in the curriculum. Clinical education sites must document satisfactory participation in extramural quality assurance programs appropriate to the practice. In the event that an institution is unable to provide the total clinical education experiences needed, arrangements with additional clinical facilities shall be made to complete the prescribed curriculum. Documentation: *Identify the clinical nuclear medicine technology staff, a description of their function in the program and information related to their education and certification. Document the sufficiency and variety of nuclear medicine procedures, examinations and equipment available to provide the full range of diagnostic and therapeutic procedures as outlined in the curriculum. (Refer to Forms CL-A through CL-C) *Identify and document participation in an extramural quality assurance program(s) appropriate to the practice. (Refer to Form CL-D). If the clinical affiliate is not accredited by a recognized agency complete the Accreditation Requirements for Clinical Affiliates of JRCNMT Programs (Form CL-G). I.B.3 Clinical Affiliates - Categories: 1. Major Affiliate - A participating institution that provides a required portion of the clinical education experience outlined in the Essentials. The length of time assigned to the clinical affiliate must be sufficient for completion of the essential training assigned to this institution. 2. Minor Affiliate - A participating institution that provides clinical education experiences not essential to fulfill the curriculum requirements of the Essentials. A student would be assigned to a minor affiliate for not more than ten business days. Documentation: *Complete the clinical information report (cover page) to identify the category of affiliation for each affiliate. *Attach a signed affiliation agreement between the sponsor and each clinical affiliate in the appropriate clinical information report. If the clinical affiliate is shared with other educational programs, the affiliation agreement should describe the allocation and assurance of available student positions for each program. I.C Accreditation Accreditation is granted to the sponsoring institution that assumes primary responsibility for curriculum planning and selection of course content; coordinates classroom teaching and supervised clinical education; appoints faculty to the program; receives and processes applications for admission; and grants the certificate or degree documenting completion of the program. The sponsoring institution shall be responsible for providing assurance that the activities assigned to students in the clinical setting are educational. Documentation: Information to be reviewed on-site.

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ESSENTIAL II RESOURCES The program's human, physical, financial and learning resources must be sufficient to support the educational goals and numbers of students admitted into the program. The instructor/student ratio shall be adequate to provide the student a learning environment in which to achieve the stated goals. Documentation: Describe the institutional policy for determining an appropriate instructor/student ration. Provide evidence that instructor/student ratios are consistent with institutional policy. II.A Human Resources Sponsor The sponsoring institution must have a qualified program director, clinical coordinator, and a medical director for the nuclear medicine technology program. Primary responsibilities shall include program development, organization, administration, evaluation and revision. The program director may assume the responsibilities of the clinical coordinator position. Affiliate In addition to the program personnel, each medical clinical affiliate must have an affiliate medical director and affiliate clinical coordinator responsible for the clinical education of the student. Radiopharmacy affiliates must have an affiliate clinical coordinator responsible for the student’s clinical education. In accordance with institutional policies and practices, these officials shall possess the qualifications and assume the responsibilities described.

Changes in any of these positions shall be communicated to the JRCNMT. If a position becomes vacant and is not filled within 60 days, or the incumbent is absent or unable to serve for 60 days, the program shall send the JRCNMT a description of the actions taken to maintain the continuity and effectiveness of the program. Documentation: See specific standards following. Note: All Curricula Vitae (Form A) must include documentation of the certification or board examination of the individual. II.A.1 Program Director II.A.1.a Responsibilities The director of the educational program shall be responsible for the organization, administration, periodic review, planning, development, and general effectiveness of the program. The director shall have input into budget preparation and provide supervision and coordination to the clinical coordinator(s). The program director may assign a clinical coordinator to supervise and coordinate the academic and clinical phases of the program. Documentation: Include completed curriculum vitae. (Refer to Form A) II.A.1.b Qualifications The program director must be a nuclear medicine technologist or a nuclear medicine physician, knowledgeable about nuclear medicine technology and education methodology. The program director must be qualified in nuclear medicine and certified by a nationally recognized certifying board, or possess suitable equivalent qualifications, and possess one of the following: 1. a baccalaureate degree in nuclear medicine technology or a related field with a minimum of two years of post-graduate professional experience, or 2. an associate degree related to nuclear medicine with a minimum of four years of post-graduate professional experience.

The program director must demonstrate effectiveness in instruction, curriculum design, program planning, evaluation and counseling. Documentation: Include completed curriculum vitae. (Refer to Form A)

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II.A.2 Clinical Coordinator II.A.2.a Responsibilities The clinical coordinator shall perform duties as assigned by the program director, e.g., provide supervision, administration, and coordination of the instructional faculty in the clinical phase of the educational program. Documentation: Include completed curriculum vitae. (Refer to Form A) II.A.2.b Qualifications The clinical coordinator shall be a nuclear medicine technologist certified by a nationally recognized certifying board and have a minimum of two years of post-certification experience in nuclear medicine technology or possess suitable equivalent qualifications. Documentation: Include completed curriculum vitae. (Refer to Form A) II.A.3 Medical Director II.A.3.a Responsibilities The medical director of the program shall provide competent medical guidance to ensure that the medical components of the curriculum meet current acceptable standards. The medical director coordinates with the program director to assure physician interaction with students and physician review and input into the curriculum. Documentation: Include completed curriculum vitae. (Refer to Form A) II.A.3.b Qualifications The medical advisor must be a physician certified in the use of radionuclides and be either a diplomate of an American Board of Medical Specialties (ABMS) approved certifying board in Nuclear Medicine, Pathology or Radiology, or possess suitable equivalent qualifications. Documentation: Include completed curriculum vitae. (Refer to Form A)

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II.A.4 Affiliate Clinical Coordinator II.A.4.a Responsibilities The affiliate clinical coordinator shall be responsible for the clinical education, supervision and evaluation of students assigned to the clinical affiliate. II.A.4.b Qualifications The affiliate clinical coordinator must be certified by a nationally recognized certifying board in nuclear medicine technology, or possess suitable equivalent qualifications.

Clinical supervisors in radiopharmacies must possess a professional license from the appropriate state board or possess suitable equivalent qualifications. Documentation: *Include completed curriculum vitae. (Refer to Form A) II.A.5 Affiliate Medical Director II.A.5.a Responsibilities The affiliate medical director shall provide input into the clinically related activities of the student and shall participate in on-site clinical instruction. II.A.5.b Qualifications The affiliate medical director must be a physician certified in the use of radionuclides and be either a diplomate of an American Board of Medical Specialties (ABMS) approved certifying board in Nuclear Medicine, Pathology or Radiology, or possess suitable equivalent qualifications. Documentation: *Include completed curriculum vitae. (Refer to Form A) II.A.6 Faculty and/or Instructional Staff II.A.6.a Responsibilities The faculty shall participate in teaching courses, supervising laboratory learning experiences, evaluating student achievement, developing curriculum, formulating policy and procedures, and evaluating program effectiveness. Documentation: Provide a chart, which identifies the assigned responsibilities for each instructional staff member, the assigned professional courses and includes his/her credentials. (Refer to Form B for academic faculty, *Form CL-A for clinical faculty) II.A.6.b Qualifications Faculty designated by the program must demonstrate, by education, certification, and experience, the ability to teach effectively at the appropriate nuclear medicine technology educational level. Documentation: (Refer to Form B for academic faculty, * Form CL-A for clinical faculty)

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II.A.6.c Professional Development The program shall document ongoing professional development of all program faculty, academic and clinical, to assure that the faculty are able to fulfill their instructional responsibilities. Documentation: Information to be reviewed on-site. II.B Physical Resources Classrooms, laboratories, administrative offices, and other facilities shall be adequate to achieve the educational objectives, assure safety, and provide barrier-free access for students, faculty, and staff. Documentation: *Provide a scaled dimensional floor plan for each clinical education center identifying the number of imaging rooms and total square footage. II.C Financial Resources Financial resources for continued operation of the educational program shall be assured by an adequate, institutionally-approved budget or by a statement of continued financial support from an executive officer of the sponsoring institution. Documentation: Attach a copy of the program budget or a statement from an executive officer ensuring financial support for the continued operation of the program. II.D Learning Resources II.D.1 Library An accessible library collection or information resource containing professional books published within the last five years, current periodicals, and other reference materials related to all subject areas of the curriculum shall be provided to foster an atmosphere of inquiry, study and learning. Documentation: Provide a list of current texts, periodicals and journals related to nuclear medicine technology subscribed to or purchased within the last five years at both the sponsoring institution and the *clinical education sites. (Refer to Form C) and Form CL-F) Describe student access, if any, to web resources. II.D.2. Instructional Aids Clinical subjects, computer hardware and software, specimens, records and related reference materials, and audio visual resources shall be available in sufficient number and quality to enhance student learning. Documentation: Information to be reviewed on-site.

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ESSENTIAL III STUDENTS The program shall address the needs of students by providing information related to the program, admission policies and procedures, student rights and responsibilities, evaluation criteria, health, and guidance services. III.A Program Description Students shall be provided with a clear description of the program and its content in the form of current publications, which must include: 1. admission criteria, both academic and non-academic, 2. program goals and course objectives, 3. a list of course descriptions, 4. supervised clinical education assignments, 5. a list of professional competencies to be obtained, 6. a description of tuition and fees with refund policies, 7. rules and regulations, including cause for dismissal and appeal procedures, and 8. program calendar, which specifies the length of program. Description: Attach current publications and demonstrate, through use of a chart, the page, which addresses items 1-8 in the Essential. (Refer to Form D) III.B Admission Policies and Procedures Admission of students, including advanced placement, shall be made in accordance with defined and published practices of the institution. Specific academic and technical standards required for admission to the program shall be defined, published, and accessible to prospective students and the public. Documentation: Attach, or reference, documentation defining the admission criteria for the nuclear medicine technology program. (Refer to Form D) III.B.1 Admission Requirements Applicants must have completed high school or the equivalent. Applicants may have prior qualifications in a clinically related allied health profession with a minimum of two years education in an accredited educational program, which includes the identified postsecondary education. Documentation: (Refer to Form D) III.B.2 Student Capacity The number of students admitted must be based on the capacity of the clinical facilities to accommodate students. Resources must be adequate to support the number of students admitted to the program. The instructor/student ratio shall be adequate to achieve the stated objectives of the curriculum. Documentation: *Complete a student capacity worksheet for each clinical affiliate and include with clinical information report. (Refer to Form CL-D). If the clinical affiliate is shared with other programs complete the Dual Capacity questions. Complete a worksheet for the total student capacity by institution. (Refer to Form E)

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III.C Student Rights and Responsibilities III.C.1 Dismissal A clear statement detailing causes for student dismissal must be published and available to the student. Documentation: Attach, or reference, documentation of the causes for which a student would be dismissed. (Refer to IIIA) III.C.2 Appeal Procedures A description of appeal procedures shall be distributed to students at the start of the program. These procedures shall include provisions for academic and non-academic types of grievances and a mechanism for neutral evaluation that assures due process and fair disposition. Rules and regulations governing acceptable conduct must be clearly defined and published. Documentation: Provide, or reference, the written policy and process available for ensuring protection of student rights. (Refer to IIIA) III.D Evaluation Criteria Written criteria for successful completion of each segment of the curriculum and for graduation shall be given in advance to each student. The evaluation system shall be related to the objectives and competencies described in the curriculum for both academic and supervised clinical education components. The evaluation system shall be employed frequently enough to provide students and program officials with timely indications of the student's progress and academic standing and to serve as a reliable indicator of the effectiveness of course design and instruction. Documentation: Attach, or reference, the institutions’ written criteria for successful completion of both the academic and clinical phases of the program. Include the frequency of the evaluations and the evaluator. (Refer to Form F, pages 1-2) III.E Health There shall be a procedure for determining whether the applicant’s or student’s health will permit achievement of the written essential standards of the program. Students shall be informed of and have access to the usual student health care services of the institution. The health and safety of students, faculty, and patients associated with educational activities shall be adequately safeguarded. Emergency medical care shall be available for students while in attendance. The program will maintain compliance with federal and state health and radiation protection regulations. Radiation exposure records shall be discussed with the students at regular intervals (not less than quarterly). Documentation of these reviews shall be maintained. Documentation: 1. Provide, or reference, any appropriate published policies. Note any applicable sections in affiliation agreements. 2. Provide evidence of the sponsoring institution’s radioactive materials license when applicable. 3. Provide documentation of quarterly reviews of radiation exposure records. III.F Guidance Guidance shall be available to assist students in understanding and observing program policies and practices and in handling professional career issues and personal problems that may interfere with progress in the program. Documentation: Identify, or reference, written institutional policies for academic guidance and personal counseling services available to students within the institution. (Refer to IIIA)

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ESSENTIAL IV CURRICULUM Curriculum content shall provide the student with a comprehensive body of knowledge and the necessary skills expected of a competent program graduate. IV.A Description of the Program All faculty, instructors and students shall be provided with a clear description of the program and its content, which includes written course syllabi (academic and clinical) with appropriate learning objectives and performance criteria for satisfactory achievement. This description must be consistent with the mission of the program and appropriate for the degree or certificate awarded. The degree or certificate must be conferred on the basis of assessed and documented educational achievement and must conform with commonly accepted standards for the certificate or degree involved. The sponsoring institution may present required educational experiences through time frames and methodologies appropriate to its mission and objectives. Documentation: Provide, or reference, the published master educational plan. The master plan should include: 1. academic instructional schedule 2. clinical rotation schedule 3. description of how the clinical assignments relate to the academic assignments. IV.B Instructional Plan The master instructional plan must document learning experiences,and curriculum sequencing to develop the necessary competencies for graduation. The curriculum shall include: (see IV.B.1.and IV.B.2.) Documentation: Provide, or reference, the sequence needed to complete the educational program. IV.B.1 Learning opportunities for students to develop personal and professional attributes and values relevant to practice. Documentation: Provide, or reference, the learning opportunities which foster development of personal and professional attributes and values relevant to practice. IV.B.2 Education in health and basic sciences, which will provide cognitive learning, experiences as a foundation to understanding and performing clinical responsibilities. Documentation: Provide, or reference, the courses utilized to provide the foundation for understanding and performing clinical responsibilities. IV.B.2.a Postsecondary education in human anatomy and physiology, physics, algebra, medical terminology, computer applications, oral and written communications, and general chemistry shall have been completed for be provided as part of the education program. Students may demonstrate competency in postsecondary requisites as appropriate by institutional policy. Institutions such as accredited junior colleges, universities, postsecondary technical institutions and hospital programs may be used to provide education in these requisites prior to or concurrent with specific courses in nuclear medicine. Documentation: Identify, or, reference where records of prerequisite education are maintained.

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IV.B.3 Academic instruction for the professional nuclear medicine technology curriculum shall include as a minimum the following content areas: 1. methods of patient care, 2. statistics, 3. nuclear medicine physics and radiation physics, 4. radiation biology, 5. radiation safety and protection, 6. radionuclide chemistry and radiopharmacy, 7. nuclear instrumentation, 8. positron emission tomography (PET), 9. computer applications for nuclear medicine, 10. diagnostic nuclear medicine imaging and non-imaging in vivo and in vitro procedures, 11. immunology as related to nuclear medicine, 12. radionuclide therapy, and 13. quality control and quality assurance. Documentation: List, or reference, the courses, which contain the identified content areas. Identify which content areas are covered in which courses. Applicants for initial accreditation should provide the objectives, course outlines and evaluation criteria for all content areas related to the professional nuclear medicine technology curriculum; applicants for continued accreditation should provide course objectives, outlines and evaluation criteria for content areas 6, 9, 10 and 13. IV.B.4 Supervised clinical education, experience and discussions shall include the following: 1. patient care and patient recordkeeping; 2. radiation safety techniques that will minimize radiation exposure to the patient, public, fellow workers and self; 3. participation in a quality control program; 4. preparation, calculation, identification, administration (where permitted), disposal of radiopharmaceuticals and

performance of all radionuclide quality control procedures; 5. performance of an appropriate number and variety of procedures to achieve desired clinical competencies; and 6. clinical correlation of nuclear medicine procedures. Documentation: Provide the master clinical rotation schedule for all students in one class. The schedule should include the name of the institution, clinical objectives, name of student or number, and the time in weeks spent for the assignment. Include the plan for student/physician interaction. Attach the performance criteria for each rotation. (Refer to Form G)

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ESSENTIAL V OPERATIONAL POLICIES Each program is responsible for ensuring integrity in all operations dealing with students, staff, patients, and the public. Documentation: Provide written documentation of information published by the program. (Refer to Form H) V.A Fair Practices V.A.1 Announcements and advertising must accurately reflect the program offered. Documentation: Attach, or reference, program publications. (Refer to Form H) V.A.2 Student and faculty recruitment and student admission and faculty employment practices shall be non-discriminatory with respect to race, color, creed, sex, age, disability conditions (handicaps) and national origin. Documentation: Provide, or reference, published non-discriminatory statements. (Refer to Form H) V.A.3 Academic credit and costs to the student shall be accurately stated, published and made known to all applicants. (Refer to Form H) Documentation: Provide, or reference, publications identifying academic credits and costs. V.A.4 The program or sponsoring institution shall have a defined and published policy and procedure for processing student and faculty grievances. Documentation: Provide, or reference, documentation of student and faculty grievance procedures. (Refer to Form H) V.A.5 Assignments during hours other than the normally scheduled clinical experience (i.e., evenings, weekends, and holidays) shall be justified. Specific objectives and evaluations must be developed to address the uniqueness of these learning experiences. Documentation: Provide, or reference, documentation regarding student supervision and employment policies. (Refer to Form H) V.A.6 Policies and processes for student withdrawal and for refunds of tuition and fees shall be published and made known to all applicants. Documentation: Provide, or reference, a copy of the withdrawal and tuition and refund policies. (Refer to Form H) V.A.7 Policies and processes by which students may perform service work while enrolled in the program must be published and made known to all concerned in order to avoid practices in which students are substituted for regular staff. Students may not take the responsibility or the place of qualified staff. However, after demonstrating proficiency, students may be permitted to undertake certain defined activities with appropriate supervision and direction outside assigned program hours. Class credit shall not be awarded for such activities. Documentation: Provide, or reference, documentation regarding student employment or unsupervised work. (Refer to Form H) V.A.8 The health and safety of patients, students and faculty must not be jeopardized in any way by activities of the students. Documentation: Provide, or reference, documentation regarding student supervision in performance of radiation procedures. (Refer to Form H)

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V.B Student Records Student records shall be maintained for admission, evaluation, and counseling or advising sessions. Individual grades and credits for courses shall be recorded and permanently maintained by the sponsoring institution. The program shall maintain the student records for a reasonable period of time (e.g., 10 years) and shall conform to applicable federal and/or state regulations. Ideally, the student files should be maintained permanently. Documentation: Provide documentation of each type of program record maintained. (Refer to Form H) ESSENTIAL VI PROGRAM EVALUATION There shall be a systematic periodic evaluation review of the program's mission and objectives and the overall effectiveness of the nuclear medicine technology program. Documentation: Provide documentation of systematic program review. VI.A Effectiveness VI.A.1 The extent to which the sponsoring institution and affiliates fulfill their responsibilities related to the mission and educational goals of the program must be assessed. Documentation: Provide the results of the indicators used to determine the effectiveness of the institution and affiliates in relationship to the program. VI.B Outcomes Programs shall routinely collect sufficient qualitative and quantitative information regarding the post-graduation activities of its graduates to demonstrate an ongoing evaluation of outcomes consistent with the graduate competencies. Documentation: Provide the qualitative and quantitative indicators used to assess the outcomes of the program. At a minimum these should include graduate employment rates, scores on certification or licensure exams and graduation rates. VI.C Results of Ongoing Program Evaluation The results of ongoing evaluation must be appropriately reflected in the curriculum and other dimensions of the program. In particular, the program must systematically use the information obtained in its evaluation to foster student achievement with respect to the certificate or degree offered. Documentation: Provide documentation that reflects program modification as a result of ongoing evaluation of graduate outcomes. * Requested information and/or documentation should be included on the Clinical Data Form.

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FORM A

CURRICULUM VITAE

NAME INSTITUTION

TITLE How many years with this program

EDUCATION: (List highest degree first) Certification* Institution Major Years Attended Degree (Cert., AA, BA) Board Year Nuclear Medicine Education (Institution): Years Attended Degree (Cert., AA, BA) *Attach documentation of your certification or board examination. Employment History in Nuclear Medicine (list most recent position first, include length of time in position) Professional organizations and Society(ies) membership:

Professional Development Activities Relevant to Nuclear Medicine Narrative description of responsibilities in NMT training program*

*Identify % of time spent in the nuclear medicine department and in the nuclear medicine program. Note: Do not send a comprehensive curriculum vitae. Use this form.

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FORM B

NUCLEAR MEDICINE TECHNOLOGY PROGRAM FACULTY

Table: Complete the following table for the nuclear medicine technology program faculty. First identify the 1) Program Director, 2) Medical Director, and 3) Clinical Supervisor for the overall program. Then identify 4) the instructors for the academic portion of the program. Include clerical staff assigned to the program. (Refer to Essential II.A.6.). Note: For individuals who work at more than one institution, use a separate line for each institution.

NAME INSTITUTION ASSIGNED COURSES

DEGREE/ CREDENTIAL

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FORM C

INSTITUTIONAL LIBRARY

Identify the number and titles of Texts, Periodicals and Journals related to nuclear medicine technology subscribed to or purchased within the last five years. (Refer to Essential II.D.1)

TEXTS NO. YEAR OF PUBLICATION

PERIODICALS NO. YEAR OF PUBLICATIONS

JOURNALS

NOTE: If needed, duplicate and insert addition pages.

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FORM D

PROGRAM DESCRIPTION

Identify the publication and page number on which each of the following policies is published. (Refer to Essential III.A.) NO. ITEM PUBLICATION PAGE NO.

1. Admission Criteria

2. Program Goals and Objectives

3. Course Descriptions

4. Clinical Education Assignments

5. Professional Competencies

6. Tuition, Fees and Refund Policies

7. Rules, Regulations, Cause for Dismissal and Appeals Procedures

8. Program Calendar

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FORM E

STUDENT CAPACITY

Complete this chart for each clinical affiliate of the program. Identify the current approved student capacity in column 2. If the affiliate is new enter zero in the column. Indicate the maximum student capacity as calculated on the individual clinical worksheets in column 3. Then indicate the number of students the program requests be assigned to the clinical affiliate at any one time. On occasion the on-site capacity may be larger or smaller than that calculated. The final number recommended for on-site student capacity must clearly ensure that space, personnel, equipment and procedure load will enable each student’s experience to satisfy the program objectives of the clinical facility. (Refer to Essential III.B.2)

STUDENT CAPACITY

NAME OF INSTITUTION APPROVED

STUD. CAP. *MAX. NO

OF STUDTS POSSIBLE.

**REQ. NO.OF

STUDTS.

TOTAL

* Indicate the maximum number of student positions each clinical affiliate could provide. ** Indicate the requested number of student positions at this clinical affiliate for this program.

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FORM F PAGE 1

METHODS AND FREQUENCY OF STUDENT EVALUATION KEY: 1 = Written Exam 4 = Written Evaluation of Student's Clinical Performance 2 = Practical Exam 5 = Research Project/Term Paper Required 3 = Oral Exam 6 = Other Indicate frequency of exams per course under appropriate numbers (Refer to Essential III.D)

COURSE TITLE 1 2 3 4 5 6

DIDACTIC COURSE

LABORATORY COURSE

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FORM F PAGE 2

KEY: 1 = Written Exam 4 = Written Evaluation of Student's Clinical Performance 2 = Practical Exam 5 = Research Project/Term paper Required 3 = Oral Exam 6 = Other Indicate frequency of exams per course under appropriate numbers. (Refer to Essential III.D)

EVALUATION METHOD AND FREQUENCY

COURSE TITLE 1 2 3 4 5 6

CLINICAL PRACTICUM/FIELDWORK

OTHER

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FORM G

MASTER CLINICAL ROTATION SCHEDULE

Provide the master clinical rotation schedule for all students in one class. The schedule should include the name of the institution, clinical assignment (see chart below), name of student or number, and the time in weeks spent for the assignment. Attach the clinical objectives and performance criteria for each rotation. (Refer to Essential IV.B.4.)

NAME OF INSTITUTION

ASSIGNMENT (SEE CHART

BELOW)

STUDENT NAME OR NUMBER

TIME SPENT IN WEEKS

Key for Assignments: - you may use more than one code for a given institution. 1. Patient care and patient recordkeeping 2. Radiation safety techniques that minimize radiation exposure to the patient, public, fellow workers and self 3. Participation in a quality control program 4. Preparation, calculation, identification, administration (where permitted), disposal of radiopharmaceuticals and

performance of all radionuclide quality control procedures 5. Performance of an appropriate number and variety of procedures to achieve desired clinical competencies

Briefly identify the procedure, e.g. GI, Cardiac, etc. 6. Clinical correlation of nuclear medicine procedures

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FORM H

OPERATIONAL POLICIES

V.A. Fair Practices

Indicate where each of the following may be found in materials supplied. If not already included please add publication to the Appendices.

TOPIC PUBLICATION PAGE #

1. Announcements/ Advertising

2. Recruitment and admission practices

3. Academic credit and costs

4. Grievance Policy

5. Non-routine Clinical Assignments

6. Withdrawal policy and refund policy

7. Student Work Policies

8. Health and Safety Policies

VB. Student Records Indicate where the following records are located.

RECORD LOCATION

a) Admission

b) Attendance

c) Evaluation

d) Transcripts

e) Radiation Exposure

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SELF-STUDY REPORT

CLINICAL INFORMATION REPORT For each clinical and extramural facility affiliated with the nuclear medicine technology program complete the following information. Please duplicate and submit a Clinical Data Form for each institution.

______________________________________________ Legal Name of Institution

______________________________________________

City, State

Major Affiliate Minor Affiliate _____ 1. Personnel: Complete Form CL-A for the nuclear medicine technology clinical staff involved in the educational

program. First identify the clinical coordinator and the medical director and then identify all personnel involved in the clinical instruction of students at this clinical affiliate. For non-patient laboratories identify the clinical supervisor and all personnel involved in the instruction of students.

2. Include a curriculum vitae for each affiliate medical director and affiliate clinical coordinator. Please limit the curricula vitae to the information requested on the curriculum vitae form (Form A). Duplicate this form as needed.

3. Nuclear Medicine Equipment: Complete Form CL-B to identify the type and number of imaging and non-imaging equipment available at this facility for student clinical education.

4. Nuclear Medicine Studies: Complete Form CL-C to report the number of in-vivo imaging, non-imaging, therapeutic and radiopharmaceutical procedures performed at this institution in the most recent 12 month period.

5. Licensure and Quality Assurance: Complete Form CL-D to identify the type of radioactive materials license in use at this institution. Identify the type of quality assurance program utilized by this institution.

6. Student Capacity: Use Form CL-E, Charts A and B to determine the student capacity at this clinical affiliate. On occasion the on-site capacity may be larger or smaller than that calculated. The final number recommended for on-site student capacity must clearly ensure that space, personnel, equipment and procedure load will enable each student’s experience to satisfy the program objectives of the clinical facility. After calculating the student capacity for this institution, transfer the desired student capacity to the program information worksheet, page 22 and on each information sheet, page 3. Are students from non-accredited programs assigned to any of the clinical education facilities approved for this program? If yes, how are the students from both programs integrated and what is the length of the assignment?

7. Clinical Library: Complete Form CL-F to identify the number and titles of texts and journals on nuclear medicine at

the clinical affiliate purchased within the last 3 years and available for student use.

8. Attach a scaled dimensional floor plan sketch for the Nuclear Medicine area. Identify administrative areas, patient care areas, imaging rooms with primary equipment, storage areas and total square footage. (Floor plan must be on 8 1/2" by 11" paper.)

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FORM CL-A

CLINICAL FACULTY AND STAFF

Complete the following table for the nuclear medicine technology clinical faculty and staff. First identify the affiliate clinical coordinator and the affiliate medical director, then identify all personnel involved in the clinical instruction of students at this clinical affiliate. For non-patient laboratories identify the clinical coordinator and all personnel involved in the instruction of students. (Refer to Essential II.A.4 and II.A.5.)

NAME

% TIME

IN NM

PRIMARY FUNCTION IN

NMT PROGRAM

FIELD OF

TRAINING/ SPECIALITY

DEGREE

CERTIFICATION

BOARD YEAR

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FORM CL-B

NUCLEAR MEDICINE EQUIPMENT

B1 - IMAGING EQUIPMENT ACCESSORIES (CHECK) IMAGING INSTRUMENT

MANUFACTURER YEAR NO. OF DET. SPECT ECG WHOLE BODY

COINCI-DENCE

MOB-ILE

B2 - NON-IMAGING EQUIPMENT COUNTING SYSTEMS

NUMBER COMPUTER SYSTEMS

FREE STANDING

NETWORKED

UPTAKE PROBES

WELL COUNTING SYSTEMS

RADIATION PHYSICS (List major pieces of equipment)

NUMBER RADIOPHARMACEUTICAL CHEMISTRY (List major equipment)

NUMBER

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FORM CL-C

NUCLEAR MEDICINE PROCEDURES C1 - IMAGING PROCEDURES Supply the number of in-vivo imaging procedures performed in this institution for the most recent 12-month period. Count as one study the total work done on a patient after administration of a dose of a radiopharmaceutical. For example, dynamic and/or static brain equals one procedure. Calculate subtotal for each category and put in appropriate column. Note: An institution may not perform all of the identified studies. Please enter zeros where a study may not be performed. Inclusive Dates of Data: From To

CATEGORY NO. CATEGORY NO. CNS Brain Planar Dynamic Spect Cisternography Routine CSF leak

XXX GENITOURINARY Renal Perfusion Function SPECT Cystography Testicular

XXX

Subtotal Subtotal THYROID Routine Metastatic survey

XXX HEMATOLOGIC Bone Marrow Lymph Nodes

XXX

Subtotal Subtotal PARATHYROID TUMOR LOCALIZATION CARDIOVASCULAR Myocardial Perfusion Rest Exercise Myocardial Wall Motion/Blood Pool Rest/Exercise Shunt Localization Infarct Avid Venography

XXX GASTROINTESTINAL Hepatobiliary Gastroesophageal Reflux Gastric emptying GI Bleeding Meckel’s Diverticulum

XXX

Subtotal Subtotal PULMONARY Ventilation/Perfusion Aerosol (particle) Quantitative

XXX SKELETAL Planar Static Whole body SPECT

XXX

Subtotal Subtotal LIVER/SPLEEN Planar Hemangioma SPECT

XXX PET

Subtotal Subtotal PYROGENIC SITE MISCELLANEOUS TOTAL NUMBER IMAGING

PROCEDURES

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FORM CL-C Continued

C2 - NON-IMAGING STUDIES Supply the number of each type of nuclear medicine procedure performed in this institution for the most recent 12-month period. Calculate subtotal for each category and put in appropriate column. An institution may not perform all the identified procedures. Enter a zero when the procedure is not performed in the institution. Inclusive Dates of Data: From To

CATEGORY NUMBER

THYROID - Thyroid Uptake GENITOURINARY Glomerular Filtration Rate Effective Renal Plasma Flow

XXX

Subtotal HEMATOLOGIC Schilling Test Cell Survival/Sequestration Red Cell mass Plasma Volume

XXX

Subtotal OTHER (SPECIFY)

TOTAL THERAPEUTIC PROCEDURES Inclusive Dates of Data: From To

CATEGORY NUMBER

Alleviation of Bone Pain Hyperthyroidism Polycythemia Vera, Chronic Leukemia Radioimmunotherapy Thyroid Carcinoma Others (Specify) TOTAL

C3 - RADIOPHARMACEUTICAL PREPARATIONS In the following table please identify which radiopharmaceuticals the students have prepared and which the pharmacy has prepared. Also identify the total number of doses of the radiopharmaceuticals the student has drawn during their clinical assignment. If no student doses are drawn please indicate. Inclusive Dates of Data: From To

NAME OF RADIOPHARMACEUTICAL

NUMBER OF KITS PREPARED BY

PHARMACY

NUMBER OF KITS PREPARED BY

STUDENT

NUMBER OF DOSES DRAWN BY STUDENT

Total Kits

Pharmacy:### Total Kits Students:###

Total Doses Drawn by Student:###

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FORM CL-D

LICENSURE AND QUALITY ASSURANCE

Licensure External Quality Assurance Programs

Radioactive Materials License (Indicate which):

Broad Specific American College of Radiology (ACR)

NRC ICANL

Agreement State JCAHO

Other (Please Describe)

FORM CL-E

Determine the student capacity for this clinical affiliate based on the Essential III.B.2 *COMPLETE BOTH CHARTS A AND B On occasion the on-site capacity may be larger or smaller than that calculated. The final number recommended for on-site student capacity must clearly ensure that space, personnel, equipment and procedure load will enable each student’s experience to satisfy the program objectives of the clinical facility. After calculating the student capacity for this institution, transfer the desired student capacity to the program information worksheet.

CHART A - CRITERION 1 ESSENTIALS PAGE 7

STUDENT CAPACITY BASED ON NO. OF IMAGING INSTRUMENTS

STUDENT CAPACITY BASED ON NO. OF IN-VITRO PROCEDURES

STUDENT CAPACITY BASED ON NO. OF RADIO-PHARMACY PROCEDURES

REQUESTED STUDENT CAPACITY

CHART B - CRITERION 2 ESSENTIALS PAGE 7

STUDENT CAPACITY BASED ON NUMBER OF FULLTIME CERTIFIED TECHNOLOGISTS

STUDENT CAPACITY BASED ON NUMBER OF PHARMACISTS, CHEMISTS, RADIATION SAFETY OFFICERS

REQUESTED STUDENT CAPACITY

Dual Clinical Affiliates 1. Will other accredited or non-accredited nuclear medicine technology training programs rotate students through this

clinical facility? (If no, proceed to next page.) 2. If yes, indicate what steps will be taken to keep the combined total within the maximum student capacity approved for

the facility. 3. Describe the method(s) used to integrate the clinical training for students from the different programs. 4. List the number of students from each program that were assigned to this clinical facility during each of the last three

years.

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FORM CL-F

CLINICAL LIBRARY

Identify the number and titles of Texts and Journals on nuclear medicine purchased within the last five years.

TEXTS: NO. YEAR OF PUBLICATION

JOURNALS: NO. YEAR OF PUBLICATION

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FORM CL-G

Extramural Quality Assurance for Clinical Affiliates of JRCNMT Accredited Programs1

Purpose: To provide the sponsoring institution with an alternative mechanism to verify that clinical education sites students attend are providing the highest quality Nuclear Medicine in agreement with generally accepted national standards of practice.

Administrative and Other Protocols The department and/or organization has clearly documented patient registration, patient billing and accounting processes that follow the CMS and HIPAA regulation. There is also a documented annual process to determine the operating and capital budget for the host department and staffing and equipment in all areas is adequate.

Patient registration process Yes No Capital and operating budget process Yes No Process of determining resources needs Yes No

Human Resources Policies and Procedures: The department has policies and procedures regarding hiring, firing, staffing levels, personnel evaluation and maintenance of competency. The department and the organization keep up-to-date job descriptions that outline the roles and responsibilities of each individual employed in the department and also lists the minimum qualifications for an individual in that position. Job descriptions Yes No Human Resources manual Yes No Personnel and Supervision: The qualification, certification and licensure of personnel are current and at a level commensurate with their job descriptions and that there is a process in place to ensure the documentation of certification and licensure is authentic.

Certification and licensure Medical Director Yes No Technical Director Yes No Medical staff Yes No Nuclear medicine technologists Yes No Direct patient care personnel Yes No Physician and nuclear medicine technologist trainees Yes No

Physical Facilities: The physical facilities are adequate and such that the safety of the staff and patients is maintained at all times. Also, that handicapped access meets all state and federal guidelines Annual Health and Safety checks Yes No Disaster, Infection Control and Fire procedures Yes No

1 All information contained within this document is drawn from the JCAHO’s, ICANL’s and ACR’s latest standards as listed on their web sites.

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Equipment and Instrumentation The department has adequate and well maintained equipment as witnessed by maintenance records and quality control records. Maintenance records Yes No Annual Health and Safety checks Yes No Quality Control Records Yes No Procedure Manual Clinical and QC Protocols The department has full documentation of all its general, clinical and equipment quality control procedures clearly outlining how, when and by whom certain tasks are to be performed. These protocols and procedures need to comply with basic standards outlined in nationally accepted practice guidelines where applicable. The department has protocols outlining image interpretation and reporting procedures. Procedure manual Yes No Radiation Safety and Radioactive Materials Handling Protocols The department and/or organization has a Radiation Safety Manual with documented procedures on Safety and Materials Handling. These guidelines are in line with NRC or State regulations. Where applicable all therapy doses are reported and records are maintained and reviewed under the Quality Management Program from the NRC. Radiation Safety Manual Yes No MSDS Sheets Yes No Quality Management Program (where applicable) Yes No State/NRC inspection Reports Yes No Outcome and Quality Assessment The department maintains a review process for administrative, technical and clinical outcomes and results to ensure that the highest quality of work product and patient care is produced at all times by all members of the team. The process must involve an assessment of these reviews, an identification process for opportunities for improvement along with an ongoing and documented process for improvement. The department and/or organization conducts regular patient and referring physician satisfaction surveys and the results of these surveys are reviewed by administration and acted upon, when applicable. Total Quality Improvement Plan Yes No Outcome and accuracy reporting Yes No

Adopted April 22, 2005

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JRCNMT ACCREDITATION SELF-STUDY REPORT

OUTLINE AND INSTRUCTIONS FOR NARRATIVE SECTION CONTENTS

Refer to the Essential and Guidelines of an Educational Program In Nuclear Medicine Technology,

Adopted 1970; revised 1976, 1984, 1991, 1997 and 2003

The Self-Study Report should reflect the findings and conclusions resulting from the self-study process in relation to compliance with the Essentials. It is to be a qualitative assessment of the strengths and weaknesses of the program and of the extent to which the program is in compliance with each Essential. It is not necessary to repeat data or information contained in the self-study, unless it is absolutely essential for the sake of clarity. The final summation should include a description of any potential future plans that you feel would strengthen the program. Include changes and/or improvements implemented as a result of the self-study or since the last review.

ESSENTIALS SECTION I: GENERAL REQUIREMENTS FOR ACCREDITATION ESSENTIAL I - SPONSORSHIP I.A Sponsoring Institution Comment on the extent to which the mission and goals of the program support the mission and goals of the institution. I.B Affiliated Institution(s) How does the sponsoring institution maintain direct supervision, coordination and communication with the affiliate(s)? If the affiliate(s) is shared with other educational programs do overlapping schedules present difficulties? Did you find opportunities for improvement? Do the clinical affiliates provide adequate experiential learning for the students? Describe the responsibilities of the academic affiliate(s), if utilized, in providing the required prerequisites and non-clinical professional curriculum. I.C Accreditation Describe how the responsibilities for the program are divided between the sponsor and the affiliates. Comment to the effectiveness of this arrangement. ESSENTIAL II - RESOURCES Provide a brief general statement concerning the overall adequacy of the program's resources to support the number of students enrolled and to achieve the stated educational goals. II.A Human Resources Describe the process used to evaluate the performance of the program director, clinical coordinator, medical director, and affiliate clinical supervisor and medical director. Did the assessment demonstrate opportunity for improvement? How did this process improve the program? Did the evaluation of the rest of the faculty and staff identify any weaknesses or strengths to build upon? How do the professional development policies contribute to the competence of the faculty in both content area and educational methodology? II. B Physical Resources Comment on the adequacy of physical facilities, including classrooms, labs, and office space assigned to or used by the program to enable the students to achieve the educational objectives. Is there a routine evaluation of physical resources to ensure student safety and to provide barrier-free access? Did the self-study reveal any additional needs in these areas?

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II. C Financial Resources Comment on whether the available financial resources are sufficient to sustain program operations as noted in this Essential. Are there any potential problems and, if so, what alternative resources may be utilized? II. D Learning Resources Comment on the adequacy of the learning resources and accessibility and availability to the students. Note any deficiencies effecting the needs of the program, and indicate how the program's learning resource needs are represented within the school or institution. ESSENTIAL III - STUDENTS III. A Program Description Comment as to whether students clearly understand the information provided regarding the program. Are there any areas that could be strengthened as a result of student feedback? III. B Admissions Policies and Procedures Did you find any area where the admissions process was confusing to the student? Did you find any area where the admissions process could be improved? III. C Student Rights and Responsibilities Did you find that student right and responsibilities are clearly understood by the students? Were any changes made in the documentation as a result of student feedback? III. D Evaluation of Students Did you find that the quality, timeliness and efficacy of student evaluation methods utilized by the program were adequate? Have changes been made in student evaluation to improve the process? If so, what changes were made and why? III. E Health Describe the health standards that must be met by program applicants. Describe the health care policy for students enrolled in the program and its relation to the institutional health care policy. Describe how students are made aware of health care services. Discuss how students are informed of radiation safety regulations, how students are monitored, and who has the responsibility for radiation exposure records? How are students informed of their radiation exposure? Have any changes been made in these policies and procedures as a result of student feedback or the self-study? III. F Guidance Were academic guidance and personal counseling provided in the past to students? Comment on the adequacy of these services. ESSENTIAL IV - CURRICULUM IV. A Description of the Program When the program was first designed how was the curriculum established? During the self-study process did you find any area(s) where change was needed? Describe the process utilized to assure the program remains up-to-date with practice changes. How are students and faculty informed of the learning objectives and performance criteria? Did the self-study reveal a need to emphasize learning objectives and performance criteria more clearly? IV. B Instructional Plan Present the master plan for the educational program. How does it provide the faculty, students and clinical affiliates with direction and a map for student learning? How did the students receive it? Were there questions indicating the plan was not clear and needed revision? What revisions were done during the self-study process?

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ESSENTIAL V - OPERATIONAL POLICIES V. A Fair Practices Describe how the integrity of program operations is evaluated consistent with the operations of the institution. V. B Student Records Describe the types of records maintained including student radiation exposure records and the policy for the maintenance of these records. ESSENTIAL VI - PROGRAM EVALUATION VI. A Effectiveness Comment on the extent the program fulfills the requirements of this Essential based on the indicators used by the program. VI. B Outcomes Comment on the extent that data from outcome surveys indicate the program is achieving appropriate graduation competencies. VI. C Results of Ongoing Program Evaluation Describe changes made in the program as a result of ongoing evaluations and the self-study process.

SUMMARY Comment to the extent that the environment the program operates within will enable implementation of any plans to strengthen the program.

REVISED 06/15/04, 05/20/05

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AUTHORIZATION TO CONDUCT ON-SITE EVALUATION

The accreditation review process can be initiated only at the written request of the chief executive officer or an officially designated representative of the institution. Accordingly, the following must be completed prior to the commencement of a site evaluation visit. JRCNMT site visitors will not request nor should they be given any information about individual patients.

SIGNATURES

Administrative Officers of Sponsoring Institution The signature of the chief administrative officer constitutes authorization to schedule site visitations and procedures required for accreditation by the Joint Review Committee on Educational Programs in Nuclear Medicine Technology.

________________________________________________ Legal Name of Institution

__________________________________________________ City, State

/ / (Print) Signature Date Chief Administrative Officer Sponsoring Institution / / (Print) Signature Date Program Director Sponsoring Institution / / (Print) Signature Date Medical Director Sponsoring Institution IF APPLICABLE / / (Print) Signature Date Dean Sponsoring Institution

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AUTHORIZATION TO CONDUCT ON-SITE EVALUATION

The accreditation review process can be initiated only at the written request of the chief executive officer or an officially designated representative of the institution. Accordingly, the following must be completed prior to the commencement of an on-site evaluation visit. JRCNMT site visitors will not request nor should they be given any information about individual patients. Duplicate and append any pages as needed .

SIGNATURES

Administrative Officers of Clinical Facility The signature of the chief administrator and the department director of Nuclear Medicine constitute authorization to schedule on-site evaluation of the facility, and to conduct appropriate procedures as part of the evaluation of the program identified in this document.

________________________________________________

Legal Name of Institution

__________________________________________________ City, State

/ / (Print) Signature Date Chief Administrative Officer and Exact Title / / (Print) Signature Date Medical Director, Department of Nuclear Medicine and Exact Title / / (Print) Signature Date Clinical Coordinator and Exact Title

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SELF-STUDY

PROGRAM INFORMATION - CHECKLIST Name of Program: Please identify the location of requested documentation by providing the Volume, Tab and Page number of the item in your final document.

ESSENTIAL - ABBREVIATED PROGRAM USE DOCUMENTATION

REVIEW COMMITTEE USE ONLY

Completed Check List Table of Contents Data Form

Location: Location: Location:

ESSENTIAL I SPONSORSHIP The nuclear medicine technology program shall be conducted in an institution that has documented its commitment to quality, integrity and performance.

Statement of the mission and goals of sponsoring institution. Location:

I.A Sponsoring Institution The sponsoring institution and affiliates must be able to provide resources needed to fulfill the mission and educational goals of the program and must be accredited by nationally recognized education accrediting agencies.

Statement of mission and goals of the program. Location: Copy of the accreditation document of the sponsoring institution. Location:

I.B Affiliated Institution(s) Affiliated institutions shall be located in geographic location that allow the sponsoring institution to maintain direct supervision, coordination and continuing communication to assure that students enrolled receive uniform and adequate instruction and clinical experience.

Description of responsibilities. Minutes of the semi-annual meetings. Location: Signed Affiliation Agreement. Location:

I.B.1 Academic Facilities The academic component of the educational program shall provide the prerequisites and/or award credit for the professional curriculum and be clearly described in written agreements.

Signed affiliation agreement between the sponsor and academic affiliate. Location:

*I.B.2 Clinical Facilities The clinical component of the educational program shall provide an environment for supervised competency-based clinical education and experience and offer a sufficient and well-balanced variety of nuclear medicine procedures, examinations and equipment.

*Clinical affiliate data form. Location:

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I.C Accreditation Accreditation is granted to the sponsoring institution that assumes primary responsibility…. The sponsoring institution shall be responsible for providing assurance that the activities assigned to students in the clinical setting are educational.

Documentation not required. Information to be reviewed on-site.

ESSENTIAL II RESOURCES The program's human, physical, financial and learning resources must be sufficient to support the educational goals and numbers of students admitted into the program.

Evidence that instructor/student ratios are consistent with institutional policy. Location:

II.A Human Resources See specific standards following. II.A.1 Program Director II.A.1.a Responsibilities The director of the educational program shall be responsible for the organization, administration, periodic review, planning, development, and general effectiveness of the program. The director shall have input into budget preparation and provide supervision and coordination to the clinical coordinator(s). The program director may assign a clinical coordinator to supervise and coordinate the clinical phases of the program.

Curriculum vitae for program director. Location:

II.A.1.b Qualifications

Documentation of certification or board examinations. Location:

II.A.2 Clinical Coordinator II.A.2.a Responsibilities The clinical coordinator shall perform duties as assigned by the program director e.g., provide supervision, administration, and coordination of the instructional faculty in the clinical phase of the educational program.

Curriculum vitae for clinical coordinator. Location:

II.A.2.b Qualifications

Documentation of certification. Location:

II.A.3 Medical Director II.A.3.a Responsibilities The medical advisor of the program shall provide competent medical guidance to ensure that the medical components of the curriculum meet current acceptable standards. The medical director coordinates with the program director to assure physician interaction with students and physician review and input into the curriculum.

Curriculum vitae for medical director. Location:

II.A.3.b Qualifications

Documentation of board exams. Location:

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II.A.6 Faculty and/or Instructional Staff II.A.6.a Responsibilities The faculty shall participate in teaching courses, supervising laboratory learning experiences, evaluating student achievement, developing curriculum, formulating policy and procedures, and evaluating program effectiveness.

Chart that identifies the assigned responsibilities for each instructional staff member teaching professional courses and includes his/her credentials. Location:

II.A.6.b Qualifications

Information to be reviewed on site.

II.A.6.c Professional Development The program shall document ongoing professional development of all program faculty, academic and clinical, to ensure that the faculty are able to fulfill their instructional responsibilities.

Documentation not required. Information to be reviewed on-site.

II.B Physical Resources Classrooms, laboratories, administrative offices, and other facilities shall be adequate to achieve the educational objectives, ensure safety, and provide barrier-free access for students, faculty, and staff.

Description of physical resources used for nuclear medicine technology program. Location:

Information to be reviewed on-site.

II.C Financial Resources Financial resources for continued operation of the educational program shall be assured….

Copy of the program budget or a statement from an executive officer ensuring financial support for the continued operation of the program. Location:

II.D Learning Resources II.D.1 Library

List of texts, periodicals and journals purchased within the last five years. Sponsoring institution. Location:

II.D.2. Instructional Aids Clinical subjects, computer hardware and software, specimens, records and related reference materials, and audio visual resources shall be available in sufficient number and quality to enhance student learning.

Documentation not required. Information to be reviewed on site.

ESSENTIAL III STUDENTS The program shall address the needs of students by providing information related to the program, admission policies and procedures, student rights and responsibilities, evaluation criteria, health, and guidance services.

See specific standards following.

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III.A Program Description Students shall be provided with a clear description of the program and its content in the form of current publications which must include: 1. admission criteria, both academic and non-academic, 2. program goals and course objectives, 3. a list of course descriptions, 4. supervised clinical education assignments, 5. a list of professional competencies to be obtained, 6. a description of tuition and fees with refund policies, 7. rules and regulations, including cause for dismissal and appeal procedures, and 8. program calendar which specifies program length.

Chart with publications addressing items 1-8. Location:

III.B Admission Policies and Procedures

Refer to III. A.

III.B.1 Admission Requirements

Refer to III. A.

III.B.2 Student Capacity

Total student capacity worksheet. Location:

III.C Student Rights and Responsibilities

III.C.1 Dismissal

Causes for which a student would be dismissed. Location:

III.C.2 Appeal Procedures

Written policy and process available for ensuring protection of student rights. Location:

III.D Evaluation Criteria

Written criteria for successful completion of both the academic and clinical phases of the program including frequency of examinations and the evaluator. Location:

III.E Health

1. Published health policies. Note any applicable sections in affiliation agreements.

2. Sponsoring institution’s radioactive materials license when applicable.

3. Quarterly reviews of radiation exposure records.

Location:

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III.F Guidance

Written institutional policies for academic guidance and personal counseling services. Location:

ESSENTIAL IV CURRICULUM Curriculum content shall provide the student with a comprehensive body of knowledge and the necessary skills expected of a competent program graduate.

IV.A Description of the Program All faculty, instructors and students shall be provided with a clear description of the program and its content.

Master educational plan. Location:

IV.B Instructional Plan The instructional plan must document learning experiences and curriculum sequencing to develop the necessary competencies for graduation. The curriculum shall include:

Sequence needed to complete the educational program. Location: Description of physician interaction. Location:

IV.B.1 Learning opportunities for students to develop personal and professional attributes and values relevant to practice.

Learning opportunities for development of personal and professional attributes and values. Location:

IV.B.2 Education in health and basic sciences, which will provide cognitive learning, experiences as a foundation to understanding and performing clinical responsibilities.

Courses utilized to provide the foundation for understanding and performing clinical responsibilities. Location:

IV.B.2.a Postsecondary education in human anatomy and physiology, physics, algebra, medical terminology, computer applications, oral and written communications, and general chemistry shall have been completed or be provided as part of the education program.

Location of records of prerequisite education. Location:

IV.B.2.b Students with prior qualifications in a clinically related allied health profession with a minimum of two years education in an accredited educational program may possess the identified postsecondary educational requirements.

Evaluation of prior allied health professional qualifications. Location:

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IV.B.3 Academic instruction for the professional nuclear medicine technology curriculum shall include as a minimum the following content areas: 1. methods of patient care, 2. statistics, 3. nuclear medicine physics and radiation

physics, 4. radiation biology, 5. radiation safety and protection, 6. radionuclide chemistry and radiopharmacy, 7. nuclear instrumentation, 8. positron emission tomography (PET), 9. computer applications for nuclear

medicine, 10. diagnostic nuclear medicine imaging and

non-imaging in vivo and in vitro procedures,

11. immunology as related to nuclear medicine,

12. radionuclide therapy, 13. quality control and quality assurance.

Courses that contain the identified content areas. Identify which content areas are covered in which courses. Applicants for initial accreditation should provide the objectives, course outlines and evaluation criteria for all content areas; applicants for continued accreditation should provide course objectives, outlines and evaluation criteria for content areas 6, 9, 10 and 13. Location:

IV.B.4 Supervised clinical education, experience and discussions shall include the following: 1. patient care and patient recordkeeping; 2. radiation safety techniques that will

minimize radiation exposure to the patient, public, fellow workers and self;

3. participation in a quality control program; 4. preparation, calculation, identification,

administration (where permitted), disposal of radiopharmaceuticals and performance of all radionuclide quality control procedures;

5. performance of an appropriate number and variety of procedures to achieve desired clinical competencies; and

6. clinical correlation of nuclear medicine procedures.

Master clinical rotation schedule for all students in one class. The schedule should include dates, clinical objectives and performance criteria for each assignment. Location:

ESSENTIAL V OPERATIONAL POLICIES Each program is responsible for ensuring integrity in all operations dealing with students, staff, patients, and the public.

See individual standards following.

V.A Fair Practices V.A.1 Announcements and advertising must accurately reflect the program offered.

Announcements and advertising. Location:

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V.A.2 Student and faculty recruitment and student admission and faculty employment practices shall be non-discriminatory with respect to race, color, creed, sex, age, disability conditions (handicaps) and national origin.

Non-discriminatory statements. Location:

V.A.3 Academic credit and costs to the student shall be accurately stated, published and made known to all applicants.

Publications identifying academic credits and costs. Location:

V.A.4 The program or sponsoring institution shall have a defined and published policy and procedure for processing student and faculty grievances.

Student and faculty grievance procedures. Location:

V.A.5 Assignments during hours other than the normally scheduled clinical experience (i.e., evenings, weekends, and holidays) shall be justified. Specific objectives and evaluations must be developed to address the uniqueness of these learning experiences.

Student supervision and employment policies. Location:

V.A.6 Policies and processes for student with- drawal and for refunds of tuition and fees shall be published and made known to all applicants.

Withdrawal and tuition and refund policies. Location:

V.A.7 Policies and processes by which students may perform service work while enrolled in the program must be published and made known to all concerned in order to avoid practices in which students are substituted for regular staff. Students may not take the responsibility or the place of qualified staff. However, after demonstrating proficiency, students may be permitted to undertake certain defined activities with appropriate supervision and direction outside assigned program hours.

Student employment or unsupervised work. Location:

V.A.8 The health and safety of patients, students and faculty must not be jeopardized in any way by activities of the students.

Student supervision in performance of radiation procedures. Location:

V.B Student Records Student records shall be maintained for admission, evaluation, and counseling or advising sessions.

Program record maintained. Location:

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ESSENTIAL VI PROGRAM EVALUATION There shall be a systematic periodic evaluation review of the program's mission and objectives and the overall effectiveness of the nuclear medicine technology program.

Systematic program review. Location:

VI.A Effectiveness VI.A.1 The extent to which the sponsoring institution and affiliates fulfill their responsibilities related to the mission and educational goals of the program must be assessed.

Results of the indicators used to determine the effectiveness of the institution and affiliates in relationship to the program. Location:

VI.B Outcomes Programs shall routinely collect sufficient qualitative and quantitative information regarding the post-graduation activities of its graduates to demonstrate an ongoing evaluation of outcomes consistent with the graduate competencies.

Qualitative and quantitative indicators used to assess the outcomes of the program, i.e. graduate employment rates, scores on certification or licensure exams and graduation rates. Location:

VI.C Results of Ongoing Program Evaluation The results of ongoing evaluation must be appropriately reflected in the curriculum and other dimensions of the program. In particular, the program must systematically use the information obtained in its evaluation to foster student achievement with respect to the certificate or degree offered.

Program modification as a result of ongoing evaluation of graduate outcomes. Location:

Comments:

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SELF-STUDY

CLINICAL INFORMATION - CHECKLIST Name of Clinical Affiliate: Please identify the location of requested documentation by providing the Volume, Tab and/or Page number of the item in your final document. Complete a clinical information checklist for each clinical affiliate. Reproduce this document as needed. This form must be included with the application.

ESSENTIAL -ABBREVIATED PROGRAM USE DOCUMENTATION

REVIEW COMMITTEE USE ONLY

Satis. Unsatis. Completed Check List Data Form (Cover Page)

Location: Location:

ESSENTIAL I SPONSORSHIP I.A Sponsoring Institution The sponsoring institution and affiliates must be able to provide resources needed to fulfill the mission and educational goals of the program and must be accredited by a nationally recognized education accrediting agency.

Signed affiliation agreement Location: Description of role /relationship of clinical affiliate to program. Location: Copy of the accreditation documents of the clinical facility. Location:

I.B Affiliated Institutions

Description of responsibilities of representatives to Advisory Committee. Location:

I.B.1 Clinical Facilities The clinical component of the educational program shall provide an environment for supervised competency-based clinical education and experience and offer a sufficient and well-balanced variety of nuclear medicine procedures, examinations and equipment.

Nuclear Medicine Equipment Imaging/Non-imaging. Location: Nuclear Medicine Procedures Imaging/Non-imaging/Pharm. Location: Quality assurance program(s). Location:

I.B.2 Clinical Affiliates - Categories: (1). Major Affiliate or (2). Minor Affiliate

Category of affiliation Location:

ESSENTIAL II RESOURCES The program's human, physical, financial and learning resources must be sufficient to support the educational goals and numbers of students admitted into the program.

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II.A.4 Affiliate Clinical Coordinator (Supervisor) II.A.4.a Responsibilities The affiliate clinical coordinator shall be responsible for the clinical education, supervision and evaluation of students assigned to the clinical affiliate.

Curriculum vitae for clinical coordinator (supervisor). Location: Description of responsibilities. Location:

II.A.4.b Qualifications

Location:

II.A.5 Affiliate Medical Director II.A.5.a Responsibilities The affiliate medical director shall provide input into the clinically related activities of the student and shall participate in on-site clinical instruction.

Curriculum vitae for affiliate medical director. Location: Description of responsibilities Location:

II.A.5.b Qualifications

Location:

II.A.6 Faculty and/or Instructional Staff II.A.6.a Responsibilities The faculty shall participate in teaching courses, supervising laboratory learning experiences, evaluating student achievement, developing curriculum, formulating policy and procedures, and evaluating program effectiveness.

Chart which identifies the assigned responsibilities for each instructional staff member teaching professional courses and includes his/her credentials.

Location:

II.A.6.b Qualifications

Location:

II.A.6.c Professional Development The program shall document ongoing professional development of all program faculty, academic and clinical, to assure that the faculty are able to fulfill their instructional responsibilities.

Documentation not required. Information to be reviewed on-site.

II.B Physical Resources Classrooms, laboratories, administrative offices, and other facilities shall be adequate to achieve the educational objectives, assure safety, and provide barrier-free access for students, faculty, and staff.

Floor plan for each clinical education center identifying the number of imaging rooms/hot lab and total square footage. Location:

II.D Learning Resources II.D.1 Library

List of texts, periodicals and journals purchased within the last five years at the clinical education sites. Location:

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II.D.2. Instructional Aids Clinical subjects, computer hardware and software, specimens, records and related reference materials, and audio visual resources shall be available in sufficient number and quality to enhance student learning.

Documentation not required. Information to be reviewed on site.

ESSENTIAL III STUDENTS

III.B.2 Student Capacity

Student capacity worksheet for each clinical affiliate. Location: Dual affiliate description Location:

III.D Evaluation Criteria

Student Evaluation Process and Frequency of Evaluation. Location:

III.E Health Services

Description. Location:

ESSENTIAL IV CURRICULUM Curriculum content shall provide the student with a comprehensive body of knowledge and the necessary skills expected of a competent program graduate.

IV.B.4 Supervised clinical education, experience and discussions shall include the following: 1. patient care and patient recordkeeping; 2. radiation safety techniques that will minimize radiation exposure to the patient, public, fellow workers and self; 3. participation in a quality control program; 4. preparation, calculation, identification, administration (where permitted), disposal of radiopharmaceuticals and performance of all radionuclide quality control procedures; 5. performance of an appropriate number and variety of procedures to achieve desired clinical competencies; and 6. clinical correlation of nuclear medicine procedures.

Master clinical rotation schedule for students assigned to this facility, including any other facility they might use. Location: Description of competencies available at this facility. Location: Radiopharmaceutical education. Location:

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ESSENTIAL VI PROGRAM EVALUATION There shall be a systematic periodic evaluation review of the program's mission and objectives and the overall effectiveness of the nuclear medicine technology program.

Description of strengths and weaknesses of this facility. Location:

ESSENTIAL VII SPONSORING INSTITUTION, PROGRAM AND JRCNMT RESPONSIBILITIES

VII.A.2.D Clinical Affiliates Signed authorization to conduct site evaluation. Location:

Comments: