Request for Special Clinical Assignment

It is expected that students secure an authorization from the site's clinical instructor prior to filling out this request because this assignment must be prearranged, preapproved, and coordinated with the program director and hospital clinical instructor. 24 hour lead time at minimum is suggested. Students are NOT authorized to attend additional clinical hours without first receiving email approval from the program director.

Students requesting additional hours or shifts are under the same rules and regulations as they are on their regularly scheduled shifts. During these shifts, students must always be under immediate supervision of a registered radiologic technologist and supervised by a clinical instructor.

The college and hospital personnel reserve the right to deny such a request if there is not adequate supervision for students on those requested additional shifts. The evening shift must end by 8:00 PM.

Your Name

Your email address:

Please enter carefully, correctly, and completely

I request to be authorized for additional clinical hours during the days and times described below:

I hereby provide the rationale(s) for such a request:

I have secured an authorization from my clinical instructor and have forwarded a separate approval email from my clinical instructor to the program director. Provide the date you have sent the authorization and your clinical instructor's email address:

I understand that I must adhere to the terms of this request and I will comply. I also understand that I cannot participate in these hours until AFTER I have received an approval via email from the program director.

Radiologic Technology

Request for Special Clinical Assignment