Medical Physics Additional Discipline Application

Purpose Of This Form

Use this application form ONLY if you are an ABR diplomate certified in at least one discipline of medical physics (diagnostic, nuclear, or therapeutic medical physics) and you are applying for ABR certification in an additional discipline of medical physics. You may seek certification in only one discipline at a time.

Before completing this form, please review information on Certification in Additional Disciplines located here:
www.theabr.org/medical-physics/initial-certification/certification-requirements/certification-additional-disciplines.

Before You Begin This Form

Before starting this form, you must have all supporting documentation (i.e., training plan, fellowship certificate/letter, candidate/supervisor CVs (if applicable), etc.) scanned and saved to your computer, as you will need to attach these within the application. You cannot save the application and return to it later.

Applicant Information
First Name*
Middle Name
Last Name*
ABR ID (located in the upper-right corner of myABR while logged in. Begins with a "P.")*
Date of Birth*

MonthDayYear
E-mail Address*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your highest degree awarded?*
Please indicate the subfield in which you are applying for certification in:

Therapeutic Medical PhysicsDiagnostic Medical PhysicsNuclear Medical Physics
Which pathway are you applying via?

Primary Pathway - 1 year of prospective/pre-approved trainingAlternate Pathway - Fellowship Training

Prospective Training Plan Details
Please list the name of the institution in which you will be completing your additional year of training.*
Supervisor's Full Name:*
Supervisor's E-mail Address:*
Start date of additional training*

MonthDayYear
End date of additional training*

MonthDayYear
Attach your prospective training plan here. The training plan must be signed by both you and your supervisor. *

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Attach any additional supporting documentation here (optional).

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Fellowship Training Details
Please list the name of the institution in which you will be completed your clinical fellowship. Note: Institution must have a CAMPEP-accredited residency or DMP program.*
Fellowship Start Date*

MonthDayYear
Fellowship End Date*

MonthDayYear
Attach your fellowship certificate or a letter signed by the program director, on institution letterhead, confirming your fellowship dates *

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By submitting this application, I agree to the terms and conditions listed above.
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