IMG Application

International Medical Graduate Alternate Pathway for Diagnostic Radiology Application for Initial Certification Examinations
Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Birthplace*
City/State/Country
Citizenship*
Country
Country of medical training*

Sponsoring Department
Name of Sponsoring Institution*
ACGME/RRC Program Number*
Name of Sponsoring Department Chair*

First NameLast Name
Sponsoring Department Chair's Email*
example@example.com
SDA Form needs to be filled out by the Sponsoring Department Chair
Sponsoring Department Agreement (SDA) signed by the department chair*

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Candidate’s responsibilities (Please check each to acknowledge)*

I acknowledge the need to attend conferences in all areas related to diagnostic radiology in order to facilitate preparation for ABR exams.I acknowledge the need for mastering all six core ACGME competencies and attest to this attainment prior to invitation to the Certifying Examination.I will visit the ABR website to review key exam dates, updates in ABR policies, and requirements of the certification process.

Medical Education
Medical School *
Institution
Location of Medical School*
City/State/Country
Degree Earned*
Year Earned*
Post-medical school training in your country of origin

Clinical Training *

	Institution	City and State	Began (MM/DD/YY)	Completed (MM/DD/YY)
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Please detail your training in diagnostic radiology in your country of origin*

	Institution	City and State	Began (MM/DD/YY)	Completed (MM/DD/YY)
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2
3

Please name any other field of residency in which you have trained

	Field	Institution	City and State	Began (MM/DD/YY)	Completed (MM/DD/YY)
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3

Other Specialty Board Certification Earned
Board
Date Earned

List any licensure or other regulatory agency certification required. If you are not yet licensed, leave this blank, but remember that you must send an update as soon as you receive your license(s)

	State/Province	Lic./Cert. No.	Expiration Date (MM/YYYY)
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The Board will assess your status relative to ABR policies and alternative pathways toward board certification only after receipt of required documents

If original documents are in a language other than English, English translation must accompany them.
Current, detailed Curriculum Vitae with specific dates of training*

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Verification of medical school training*

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Verification of foreign clinical year training with dates of completion*

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Verification of foreign radiology residency with dates of completion*

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Verification of foreign radiology board certification*

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Copy of ECFMG certificate or LMCC certificate*

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Copies of USMLE Steps (1-2) score reports*

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Copy of USMLE Step 3

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*Will be required six months prior to the Certifying Examination Cancelof
Copy of current medical license

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*Six months prior to the Certifying Examination you will be required to update your license information Cancelof

PLEASE READ CAREFULLY BEFORE SIGNING

Agreement for Candidates and Diplomates
• I, the undersigned, hereby register with the American Board of Radiology, Inc. (hereinafter the “Board” or “ABR”) for its Initial Certification and Maintenance of Certification (MOC; also known as Continuous Certification) processes, in accordance with and subject to the policies, procedures, and Bylaws of the Board, as they may be amended from time to time.

• By entering into this Agreement for Candidates and Diplomates (hereinafter the “Agreement”), I pledge myself to the highest ethical standards in the practice of my discipline.

• I agree to disqualification from examination or from issuance of a certificate in the event that any of the statements herein made by me are false, or if I violate any of the policies, procedures, or Bylaws of the Board.

• I agree to timely payment of Initial Certification fees during training and the period when I am enrolled in the Initial Certification process but not yet certified.

• I recognize the trustees of the Board as the sole and only judge of my qualifications to receive and to retain a certificate issued by the Board. I understand and agree that as a registrant or a diplomate of the Board, I have the responsibility to supply the Board with information adequate for the Board’s proper evaluation of my character and my credentials.

• Additionally, I hereby request and authorize any hospital or medical or professional organization of which I am a member, have been a member, or to which I have applied for membership, and any person who may have information that is deemed by the Board to be material to its evaluation of my registration or certification, to provide such information to representatives of the Board upon their request. I agree that communication of any nature made to the Board regarding my registration or certification may be made in confidence and shall not be made available to me under any circumstances. I hereby release from liability any hospital, medical staff, medical or professional organization or person, and the Board and its trustees and other representatives, from liability for acts performed in good faith and without malice in connection with the provision, collection, or evaluation of information or opinions, whether or not requested or solicited by the Board in connection with my registration or certification.

• I understand and agree that in consideration of my registration, my moral, ethical, and professional standing will be reviewed and assessed by the Board; that the Board may make inquiry of the persons named in my registration form and of such other persons and entities as the Board deems appropriate with respect to my moral, ethical, and professional standing; that if information is received that would adversely affect my registration, I will be so advised and given an opportunity to rebut such allegations, but I will not be advised as to the identity of any individual or entity who has furnished adverse information concerning me; and that all statements and other information furnished to the Board in connection with such inquiry shall be confidential, and not subject to examination by me or by anyone acting on my behalf.

• I agree that I will not use any litigation process, subpoena, or other means to cause or attempt to cause any disclosure of the contents of any registration form, including my own, or any proceedings of any committee’s evaluation of such registration form or of my certification, whether such disclosure is by operation of law of otherwise.

• I accept that the Board determines admissibility to all qualifying, certifying, and MOC examinations, and that each examination is supervised by proctors who are responsible to the Board and are empowered by the Board to ensure that the examination is conducted ethically and in accordance with the rules of the Board. I understand that I must bring government-issued photo identification to any examination that I attend. Such government-issued photo identification includes one of the following: state-issued driver’s license, military ID, passport, or state-issued ID.

• I give my consent to be photographed and to the collection of my biometric data, which the Board will use solely for the purpose of confirming my identity as the eligible examinee.

• I understand that no pager, recorder, camera, PDA, cellular phone, or any device that has the capability to record or transmit pictures, text, or sound can be brought to the examination; and that I am not permitted to bring into the examination any notes, scratch paper, textbooks, calculators or other reference materials. I further understand that any irregular behavior before, during, or after the examination, such as copying answers, sharing information about specific questions or answers, using notes during any examination, or otherwise giving or obtaining unauthorized information or aid — evidenced by observation, statistical analysis of answers, or otherwise — on any portion of the examination will constitute grounds for the invalidation of my examination and may lead to my being judged unacceptable for certification by the Board.

• I recognize that all ABR examination materials are copyrighted as the sole property of the Board and must not be removed from the test area or reproduced, in whole or in part, through memorization or by any other means, and that any reproduction of copyrighted material is a federal offense, and may also subject me to discipline by the Board in accordance with its policies and procedures. In the event that the Board conducts a hearing into an examination irregularity at which I am either the subject of the investigation or a witness to the actions of one or more other examinees, I will cooperate fully with the Board, including appearing at any hearing and providing testimony.

• To help analyze the effectiveness of the training program and/or department in which I prepared for my examination(s), I hereby authorize the Board to release, in confidence, to the director(s) of the program in which I am enrolled or was formerly enrolled, and to the chair of the department of which the program is a part, the results of my performance on the examinations conducted by the Board.

• Throughout my candidacy for initial primary (general) or subspecialty certification, I consent to have my name and demographic data published, along with my board-eligibility status. If I become certified, I consent to have my name and demographic data (including type and date of all ABR certifications and MOC status) included in any list or directory in which the names of diplomates of the specialty boards are published. I agree that the Board is not liable for information provided to the medical community or to the public regarding my certification status, and I further agree that I will promptly notify the Board of any error or omissions in such information.

• If I become certified, I understand and agree that the continued validity of my certificate will be contingent upon my meeting the requirements of the Maintenance of Certification Program (ABR-MOC) administered by the Board, as amended from time to time. I understand that the ABRMOC program is designed to monitor my professional standing, lifelong learning and self-assessment, cognitive expertise, and practice quality improvement, each an MOC component for which I am responsible. I agree to participate in ABR-MOC in accordance with and subject to stated policies and procedures, as amended from time to time, including timely payment of fees. The Board does not undertake any responsibility to provide individual diplomates with notice of changes to MOC policies. I further understand that it is my responsibility to stay informed regarding all phases of the MOC program and my progress therein, through myABR and the ABR website. I will keep truthful and accurate records of my participation in the MOC program, and I will promptly advise the Board of any change of my current contact information.

• I understand that it may be necessary to revise and update this Agreement at a later date, and that as a condition of continued certification and/or participation in MOC, I may be required to execute and return to the Board a revised Agreement, which shall replace and supersede the terms of this Agreement. The portions of this Agreement relating to examination security are subject to modification by the Board in the most current version of its Exam Security Policy, which is posted on its website and/or in specific agreements that may be required in order to register for or to take an examination.

• I waive and release and shall indemnify and hold harmless the Board and its trustees, directors, members, officers, committee members, employees, and agents from, against, and with respect to any and all claims, losses, costs, expenses, damages, and judgments (including reasonable attorneys’ fees) alleged to have arisen from, out of, with respect to, or in connection with any action that they, or any of them, take or fail to take as a result of or in connection with this Agreement; any examination conducted by the Board that I apply to take; the grade or grades given me on the examination; and, if applicable, the failure of the Board to issue me a certificate or qualification or the Board’s revocation, suspension or probation of any certificate or qualification previously issued to me; and/or the Board’s notification of any interested parties of its actions.
By signing this application, I agree to the terms and conditions listed above.*

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Date Signed *

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International Medical Graduate Alternate Pathway for Diagnostic Radiology Application for Initial Certification Examinations

Sponsoring Department

Medical Education

Post-medical school training in your country of origin

The Board will assess your status relative to ABR policies and alternative pathways toward board certification only after receipt of required documents

PLEASE READ CAREFULLY BEFORE SIGNING