Form (B) IIR/RQRB

IRISH INSTITUTE OF RADIOGRAPHY

RADIOGRAPHERS QUALIFICATIONS REVIEW BOARD
FORM B DIAGNOSTIC IMAGING
The Irish Institute of Radiography (IIR) is the professional body designated by the Department of Health as the Competent Body for the alidation of non!national radiographi" #ualifi"ations in a""ordan"e $ith %& Dire"ti e '(/)'* In the republi" of Ireland+ Radiography is a single dis"ipline four!year honours degree "ourse* %a"h appli"ation for alidation is assessed on the information supplied by the appli"ant* Applicants can apply for validation in either Diagnostic I aging or Radiation Therapy! ,ssessment for both is -.T a ailable* /e re"ommend all appli"ants 0eep a full re"ord of appli"ation* IIR/RQRB "annot a""ept responsibility for any loss that o""urs* This for is to "e co pleted "y the applicant in #nglish* The for$arding of a syllabus $ill not suffi"e* In the interest of fairness and e#uality a personal re"ord of your sub1e"ts and hours is re#uired* NOTARISATION OF FORM Documents must be signed and stamped by a Public Notary, Peace Commissioner, Member o an !arda S"oc#$na or Solicitor %T#e signatory must not be a relati&e o t#e applicant'( T#e signatory) %a( must S** t#e original document and sign to t#at e ect on t#e p#otocopy+ %b( must state t#at t#e p#otocopy is a true copy o t#e original document ,#ic# #as not been altered in any ,ay, by ,riting -T#is p#otocopy is a true copy o t#e original document ,#ic# #as not been altered in any ,ay. on t#e p#otocopy+ %c( must PRINT t#eir name ,it# t#e company stamp, position and contact address and telep#one number on t#e p#otocopy+ %d( must DAT* t#e copy+ %e( must sign t#e p#otocopy using blac/ in/' Additional doc$ entation to acco pany this for Dire"ti e 2334/56 on the re"ognition of professional #ualifi"ations applies to %%, nationals and to persons $hose third!"ountry professional #ualifi"ations ha e been re"ognised by another %%, member state and $ho ha e pra"ti"ed the profession for three years in that member state* In "ertain restri"ted instan"es+ the Dire"ti e may also be applied to non!%%, nationals $ho are legally resident in Ireland* 7* 8roof of Citi9enship i*e* a notarised "opy of your Birth Cert/8assport indi"ating that you are an %uropean %"onomi" ,rea (%%,) national*

Nationals of the #$ropean #cono ic Area Are yo$ a National of the #$ropean #cono ic Area %##A& i!e! fro the Me "er States of the #$ropean 'nion( Iceland( )eichenstein or Nor*ay& or of S*it+erland ,#S - NO NON ##A NATIONA)S IF yo$ are not a an ##A national( are yo$ legally resident in Ireland ,#S - NO -

Form (B) IIR/RQRB

If yes please s$pply a notarised copy of. %a& ,o$r certificate of registration %doc$ entary evidence that yo$ are la*f$lly in the state *hich is iss$ed "y the Garda National I igration B$rea$ %GNIB& and sho*ing the i igration sta p %"& /assport endorse ent The period of per ission sho*n in the certificate and the passport sho$ld atch! 2* Copy of original diploma/degree and a trans"ript of all e:am results sho$ing sub1e"ts studied and grades obtained*

5* ,"ademi" re"ord )* Do"umentation to indi"ate that your #ualifi"ation entitles you to pra"ti"e as a diagnosti" radiographer in the "ountry $here your gained your #ualifi"ations*

4* Fee of ;733 < $hi"h must be dra$n on an Irish Ban0 and payable to the Irish Institute of Radiography* 6* If appropriate!! =arriage Certifi"ate0Change of na e certificate >* ?hould the appli"ant ha e any additional information they thin0 is rele ant+ an outline $ill suffi"e* If re#uired it $ill be re#uested* A//)ICANT 1! /ersonal Details -ame of ,ppli"ant @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ ,ddress @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ IF yo$ are not a an ##A national( are yo$ legally resident in Ireland ,#S - NO If yes please s$pply a notarised copy of. %a& ,o$r certificate of registration %doc$ entary evidence that yo$ are la*f$lly in the state *hich is iss$ed "y the Garda National I igration B$rea$ %GNIB& and sho*ing the i igration sta p %"& /assport endorse ent The period of per ission sho*n in the certificate and the passport sho$ld atch! Date of Birth @@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

,ddress for "orresponden"e If different

Form (B) IIR/RQRB

-ationality =ale/Female

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@

Aear Qualified @@@@@@@@@@@@@@@@@ 2! General #d$cation Date of ?e"ond Be el %du"ation FromC ToC -o*of AearsC

?ub1e"ts studied during se"ond le el edu"ation ?ub1e"t Date of ?tudy From To -ame of Certifi"ate $ith grade $here appropriate

3!

Other Non4/rofessional #d$cation ,dditional post se"ond le el edu"ation or #ualifi"ations other than in radiography or radiotherapy ?ub1e"t Date of ?tudy From To -ame of Certifi"ate $ith grade $here appropriate

Form (B) IIR/RQRB

5! a! Is #nglish yo$r first lang$age6

AesC

-oC

If -o+ $hat is your le el of "ompeten"yD % iden"e of Competen"y .ral e:amination /ritten e:amination -one "! If -o+ $as your Diagnosti" Imaging "ourse "ondu"ted in %nglishD %:"ellent Eery Food Food

c!

/hat G of your "urrent patient $or0load do you treat using %nglishD

7!

Radiographic #d$cation Institution/?"hool/ Hospital of study/&ni ersity -ame ,ddress

Fo erning Body/ 8lease ti"0

?tate &ni ersity Hospital 8ri ate .ther+ please spe"ify

Form (B) IIR/RQRB

Form (B) IIR/RQRB

/RO9#CT D#TAI)S Did you "omplete a pro1e"t as part of your undergradate studiesD If AesC 8lease state 7* Title

2* Bength of 8ro1e"t /ord Count

/ro:ect Str$ct$re /hi"h of the follo$ing elements $as "o ered in your resear"h pro1e"tD* Biterature Re ie$ Resear"h =ethodology Questionnaire Retrospe"ti e re ie$ Data ,nalysis ?tatisti"al ,nalysis Dis"ussion of Findings Con"lusions Re"ommendations

Form (B) IIR/RQRB

>* Radiographic ;$alification o"tained Title (in full)

<! Co$rse Details 8lease "omplete .-BA for /ri ary Diagnosti" Imaging #ualifi"ations -ormal Course Duration (years) Date Course "ommen"ed Date Course "ompleted

=!

C)INICA) INFORMATION Did your Clini"al 8ra"ti"e in"lude %le"ti e 8la"ement %le"ti eC state Re"urrent %le"ti e Hospital(s)

If Aes ?tate

Bength of pla"ement (in hours)

Did you e:perien"e any prolonged absen"e i*e* o er 6 $ee0s/a monthD If Aes state if time needed to be made up

>

Form (B) IIR/RQRB

1>! -B

Co$rse Content please indi"ate any offi"ial re"ord of "lini"al pra"ti"e $ith this appli"ation form*

&se Aear 7+ Aear 2 et"* to indi"ate $hi"h year(s) sub1e"t(s) $ere "o ered/studied

,"ademi" ?ub1e"ts
?ub1e"t Aear 7

Clini"al 8ra"ti"e
Bist range of e:perien"e you gained during your "lini"al pra"ti"e %:perien"e

Aear 2

Aear 5

Aear )

'

Form (B) IIR/RQRB

11!

Details of Em lo!me"t as a Ra#io$%a &e% Enter all radiographic positions held in date order beginning with most recent Please e"s'%e t&at !o' e( lai" a"! $a s i" !o'% )o%* &isto%! o" t&is fo%m
TITLE OF POSITIO HELD AME ! ADDRESS OF EMPLO"ER F#LL OR PART TIME LIST E$PERIE %E RESPO SI&ILITIES A D E'#IPME T #SED %O TA%T AME I THIS I STIT#TIO

DATES HELD FROM TO

Form (B) IIR/RQRB

12!

/ost Grad$ate or other post ?$alification ed$cation in radiography! 8lease "omplete for all "ourses and "ontinue on separate sheet if ne"essary*

Course Title 8la"e studied Type of "ourse+ 8lease ti"0 Course "ommen"ed Course "ompleted Full or part!time Brief summary of "ourse "ontent &ltrasound =agneti" Resonan"e Imaging Computed Tomography Radionu"lide Imaging Therapy planning .ther+ please spe"ify

Type of assessment Full title of a$ard obtained Course Title 8la"e studied Type of "ourse+ 8lease ti"0 Course "ommen"ed Course "ompleted Full or part!time Brief summary of "ourse "ontent

%:amination .ral 8ro1e"t /or0 =CQHs

/ritten Continuous ,ssessment .ther Course /or0

&ltrasound =agneti" Resonan"e Imaging Computed Tomography Radionu"lide Imaging Therapy planning .ther+ please spe"ify

73

Form (B) IIR/RQRB

Type of assessment Full title of a$ard obtained

%:amination .ral 8ro1e"t /or0 =CQHs

/ritten Continuous ,ssessment .ther Course /or0

75* Ha e you attended any "onferen"e /study days sin"e #ualifi"ation* If Aes gi e details Bo"ally

-ationally

Internationally

15!

SIGNAT'R# OF A//)ICANT

The abo(e statement sets o)t a tr)e record o* m+ ed)cation and e,perience in Diagnostic Imaging-

Signed.

///////////////////////////

Date. /////////////////

Any false declaration *ill res$lt in yo$r validation "eing re oved!

77

Form (B) IIR/RQRB

STAT*M*NT 0 RADIO!RAP12
Any recognition granted on the basis of fraudulent or falsified information, material misrepresentation or misstatement designed to mislead the IIRRT, shall be invalid and may be subject to criminal sanctions. The onus for ensuring the full and accurate disclosure of information rests with the applicant. Imaging or treatment of patients for which the applicant does not have the necessary competence is defined as a breach of the Code Practice of the IIRRT, and could lead to steps being ta en resulting in the practitioner being struc off and rendered ineligible to practise the regulated profession. ! ! ! I declare that the information given in this document and in all attached forms is true and accurate. I declare that I have not made a previous application for validation"recognition and that I have read, understood and agree to abide by the IIRRT code of conduct #www.iir.ie$. I declare that I have not been found guilty by any recognised professional body having jurisdiction in the matter of any professional misconduct or am under current investigation within the scope of my profession as a diagnostic radiographer or radiation therapist resulting in the imposition of any suspension, fine, penalty or disciplinary measure. I declare that I am fit to carry on the practice of diagnostic imaging or radiation therapy in the language of the area of Ireland where I intend to practice. I understand that failure to disclose full information, or any deliberate misrepresentation of information, is a serious matter and will invalidate my application. I agree to notify the IIRRT, in writing, of any change of personal details, e.g. change of surname or address, as and when any such changes occur. ''''''''''''''''''''''''''''''''''''''''''

! ! !

%ame of Applicant&

(ignature of Applicant& ''''''''''''''''''''''''''''''''''''''''''' )ate& '''''''''''''''''''''''''''''''''''''''''''

72

Form (B) IIR/RQRB

NOT*S *. Recognition of professional +ualifications is not to be regarded as an endorsement or a declaration of the applicant,s suitability for employment in any particular post, which is a separate matter for assessment by the employer in the normal way in accordance with the prescribed selection criteria.

-.

Recognition of professional +ualifications does not give automatic right to membership of the IIRRT. If your application for recognition is successful you can apply for membership of the IIRRT through the website #www.iir.ie$.

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VALIDATION PROCESS EU DIRECTIVE 89/48 REQUIRED INFORMATION SOUGHT IN AGREEMENT WITH DEPARTMENT OF HEALTH & CHILDREN %hec0list 1Form A 2 F)ll+ completed3 dated3 signed and stamped 4Form & 579Proo* o* %iti6enship i-e- cop+ o* birth certi*icate or passport %op+ o* original diploma8degree Academic record

:Fee o* ;1<< which m)st be drawn on an Irish &an0 and pa+able to the Irish Instit)te o* Radiograph+=Doc)mentation to indicate that the >)ali*ication entitles the applicant to practice as a Diagnostic Imaging Radiographer in the co)ntr+ where the >)ali*ications were obtained?AI* appropriate @ Marriage %erti*icate

Sho)ld +o) ha(e an+ additional in*ormation +o) thin0 is rele(ant a list8o)tline onl+ o* the in*ormation need be incl)ded- Sho)ld the R'R& re>)ire the additional in*ormation the+ will re>)est it to be *orwardedCom lete# A li+atio"s s&o'l# ,e se"t toA""ette L!o"s P%ofessio"al E#'+atio" Natio"al Vali#atio" P%o.e+t Healt& Se%/i+e E(e+'ti/e HR Di%e+to%ate 0e%li" Pa%* Gal)a! Tel- 123 445126 THE VALIDATION PROCESS-

E7mail- A""ette8l!o"s9&se8ie

75

Form (B) IIR/RQRB

The application will be chec0ed in the Balwa+ o**ice and the sent to the IIR8R'R&3 i* complete A letter o* ac0nowledgement will be sent to the applicant b+ the Balwa+ o**ice with a re*erence n)mberIf a" a li+atio" is i"+om lete it )ill ,e %et'%"e# to t&e a li+a"t Follo)i"$ assessme"t The Balwa+ o**ice will be noti*ied o* the o)tcome b+ the IIR8R'R& The Department o* Health ! %hildren will in*orm the applicant o* the o)tcome o* the (alidation process-

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