Medical Physics Structured Mentorship
Discipline in which you are seeking certification
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Therapeutic Medical Physics
Diagnostic Medical Physics
Nuclear Medical Physics
Name
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First Name
Middle Name
Last Name
Gender
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Birthplace
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Citizenship
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Country of Medical Physics Training
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Name of Sponsoring Institution
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Department within Institution
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Name of Department Head
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Phone Number
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Area Code
Phone Number
Email
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example@example.com
Name of supervising Medical Physicist (must be ABR certified)
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Phone Number
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Area Code
Phone Number
Email
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example@example.com
Business Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Highest Degree Awarded/Institution Name
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Location of Institution
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Please detail your training in fundamental physics in your country of origin
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Rows
Institution
City, State
Began (MM/DD/YY)
Completed (MM/DD/YY)
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Please detail your training in medical physics in your country of origin
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Rows
Institution
City, State
Began (MM/DD/YY)
Completed (MM/DD/YY)
1
2
3
Please list any staff and/or teaching appointments you have held
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Rows
Position/Field
Location
Began (MM/DD/YY)
Ended (MM/DD/YY)
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Documents that must be submitted by the candidate for review
Academic transcripts (undergraduate and graduate): Must have an MS or PhD from an institution of higher education with at least the equivalent of a minor in physics
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Evaluation by an ABR-approved credentialing evaluation organization stating that the foreign academic degrees received are equivalent to those given by accredited U.S. institutions.
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Documentation/ evidence that the candidate has an education equivalent to at least the requirements of an MS degree in medical physics from a CAMPEP- accredited program (www.campep.org)
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Copy of any documents reflecting qualified medical physics status in foreign country of origin (e.g., professional certificates, license to practice medical physics, etc.)
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Documentation of employment as a clinical medical physicist in the foreign country of origin (minimum of 1 year).
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Verification of current employment as a medical physicist in the United States.
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Sponsoring Institution/Department Agreement that includes attestation as to clinical facilities/equipment available per specification of the clinical rotation plan. Finalized plan of clinical rotations. ABR-certified physicians available for supervision and mentoring should be listed for each rotation.
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Signature
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Candidate Signature
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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