Medical Physics Structured Mentorship
Discipline in which you are seeking certification
*
Therapeutic Medical Physics
Diagnostic Medical Physics
Nuclear Medical Physics
Name
*
First Name
Middle Name
Last Name
Gender
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Birthplace
*
Citizenship
*
Country of Medical Physics Training
*
Back
Next
Name of Sponsoring Institution
*
Department within Institution
*
Name of Department Head
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Name of supervising Medical Physicist (must be ABR certified)
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Highest Degree Awarded/Institution Name
*
Location of Institution
*
Please detail your training in fundamental physics in your country of origin
*
Rows
Institution
City, State
Began (MM/DD/YY)
Completed (MM/DD/YY)
1
2
Please detail your training in medical physics in your country of origin
*
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
*
Rows
Position/Field
Location
Began (MM/DD/YY)
Ended (MM/DD/YY)
1
2
3
4
Back
Next
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
*
Browse Files
Cancel
of
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.
*
Browse Files
Cancel
of
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)
*
Browse Files
Cancel
of
Copy of any documents reflecting qualified medical physics status in foreign country of origin (e.g., professional certificates, license to practice medical physics, etc.)
*
Browse Files
Cancel
of
Documentation of employment as a clinical medical physicist in the foreign country of origin (minimum of 1 year).
*
Browse Files
Cancel
of
Verification of current employment as a medical physicist in the United States.
*
Browse Files
Cancel
of
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.
*
Browse Files
Cancel
of
Back
Next
Signature
*
Candidate Signature
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: