Ethics Review Pre

Ethics Review Pre
Ethics Review Pre-Application Packet
About the Ethics Review Pre-Application
The Ethics Review Pre-Application provides an early ethics review of violation(s) that would otherwise need to be
reported on your Application for Certification and Registration when you have completed an ARRT-recognized educational
program.
This form is reserved for those who are:
• not yet enrolled in an ARRT-recognized educational program, or
• enrolled in an ARRT-recognized educational program and are at least
six months away from graduation.
Note that the review applies only to violations specified in the
Ethics Review Pre-Application packet; it does not apply to any
violations not reported or occurring after submission of the Ethics
Review Pre-Application.
Submission of the Ethics Review Pre-Application does not waive
any other ARRT eligibility and application requirements. An
Application for Certification and Registration must still be submitted
at the time of graduation.
If you are within six months of
your graduation, do not use
this form. Instead, submit the
information identified in this
packet with your Application for
Certification and Registration,
available from your program
director, along with the required
Application for Certification and
Registration fee.
What to report
The Ethics Review Pre-Application may be used to report the following:
• Criminal proceedings including:
- misdemeanor charges and convictions,
- felony charges and convictions,
- military court-martials; and/or
• Disciplinary actions taken by a state or federal regulatory authority or certification board; and/or
• Honor code violations.
Information on the types of documentation that need to be included with the form can be found on
the next page.
Cost
The Ethics Review Pre-Application fee is $100 and is non-refundable and non-transferable.
Checklist
Before submitting, be sure to complete these four steps:
1. Complete the Ethics Review Pre-Application form.
2. Sign the Agreement in the presence of a notary.
3. Enclose all required documentation (see next page). Forms submitted without documentation will not be
processed and will be returned.
4. Enclose the $100 Ethics Review Pre-Application fee via a personal check or money order payable to ARRT.
Rev. 12/2014
The following information must be provided
with the Ethics Review Pre-Application.
Incomplete Ethics Review Pre-Applications will not be reviewed and will be returned.
For criminal violations
Charges or convictions that were: plea of guilty, plea of no contest (nolo
contendere), withheld/deferred adjudication, stayed, set aside, suspended,
or pre-trial diversion.
• Personal explanation of the events that led to each charge or conviction.
Applications are not complete until this explanation is provided.
•
Copies of official court documents* to confirm:
- The charges filed (misdemeanor, felony, or military court-martial),
- The date and jurisdiction in which the charges are pending,
-The final judgment (guilty, nolo contendere [no contest], withheld or
deferred adjudication, suspended or stay of sentence, set aside, or
pre-trial diversion),
- The sentencing requirements (parole, probation, fines), and
- The status of the conditions of the court (e.g., completed, case
closed, dismissed).
•
Exceptions that do not need to be reported are:
- Offenses committed while a juvenile and
processed in the juvenile court system,
- Traffic violations that did not involve drugs or alcohol (e.g., speeding or parking ticket),
- Charges that were dismissed if there were no court conditions required, and
- Sealed or expunged cases (must have
specific court documents attesting to the
sealing or expungement).
* Documents may usually be obtained by
request at the courthouse in the jurisdiction
in which the charge or conviction occurred.
Send copies, not originals. The application is
not complete until the court documents are
received and reviewed.
If you are currently on probation or parole, a current update from your probation or parole officer is required, including the estimated probation or parole completion date. This must be printed or typed on official stationery and must include the telephone number of the office. It may be mailed directly from the probation or parole office to the ARRT office at
1255 Northland Drive, St. Paul, MN 55120-1155.
• If you have completed the requirements of the court, proof of completion of probation or parole is required. A copy of the official court release documents or the release letter on official court stationery must be provided.
• Documentation of completion of any court ordered remedial programs and community service (if applicable).
• Status of any counseling or treatment (if applicable), and/or documentation of completion.
• Any documents submitted that do not match the name indicated on the Ethics Review Pre-Application must be accompanied by documentary evidence of the change (e.g., copy of marriage certificate or court order showing name change).
• Letters of recommendation may be provided (e.g., from employers, instructors, court officials).
For regulatory authority or certification board violations
An action by a state or federal regulatory authority or certification board resulting in the individual’s professional license, permit,
registration, or certification being denied, revoked, suspended, placed on probation, under consent agreement or consent order,
voluntarily surrendered, or subjected to any conditions or disciplinary actions.
• Personal explanation of the events that led to the violation.
• Official documentation of any agreement or disciplinary action taken by a state or federal regulatory authority or certification board.
• Copy of your state license (if applicable).
• Letters of recommendation may be provided (e.g., from employers, instructors, court officials).
For honor code violations
A suspension, dismissal, or expulsion from an educational program attended in order to meet ARRT certification requirements.
• Personal explanation of the events that led to the suspension, dismissal, or expulsion.
• Copy of all correspondence between you and your educational program regarding the incident and/or disciplinary
action taken.
• Letters of recommendation may be provided (e.g., from employers, instructors, court officials).
The American Registry of Radiologic Technologists®
1255 Northland Dr., St. Paul, MN 55120-1155 • Phone (651) 687-0048
NOTE: If you are within six
months of your graduation,
do not use this form.
ETHICS REVIEW
PRE-APPLICATION
Complete Front and Back of Application. Failure to provide complete and accurate information in each of the
boxes or to include the correct fee will result in an incomplete application, which will be returned. Print Legibly.
Forms with smudged print will be returned as incomplete. Include Payment. Fee is $100 in US funds. Make check
payable to ARRT. Fee is not refundable or transferable. Payment of fee is not deductible as charitable contribution,
but may qualify as an employee business expense deduction on your personal tax return. For more information,
call the IRS Service Center at (800) 829-1040. Mail to ARRT. The completed pre-application form and payment
should be mailed to 1255 Northland Dr., St. Paul, MN 55120. For More Information. Consult www.arrt.org or
call ARRT at (651) 687-0048, ext. 8580.
Do not write in space below
For ARRT use only
Last
Name
Name on application must be legal name and match name on two IDs presented at test center. See handbook for details.
First
Name
Middle Initial/Name
Mailing
Address
City
State/Prov
Zip/PC
Birth Date
Month
Day
Gender
Year
Social Security Number
—
Male
—
(US citizens only)
Female
No Social Security Number
(Not a US citizen)
Have you applied for or are you currently enrolled in a radiologic technology program? If you are within six months of your
graduation, do not use this form.
No
Yes: If “Yes,” what is the projected date for completion of your educational program?
Month
Day
Year
Have you previously submitted to ARRT an Application for Certification and Registration in radiography, nuclear medicine
technology, radiation therapy, sonography, or magnetic resonance imaging, or an Ethics Review Pre-Application?
No
Yes: If “Yes,” provide your ARRT ID number and any previous names.
ARRT ID Number
Previous Name(s)e side to complete applican
Sign the Ethics Review Pre-Application Agreement on the next page
Ethics Review Pre-Application Agreement
I hereby request ARRT to review my records as they relate to the requirements for ARRT certification and registration as
described in the ARRT Rules and Regulations and to the requirements of my compliance with federal and state laws in
accordance with the ARRT Standards of Ethics. I understand that a full and complete copy of the ARRT Rules and Regulations
and ARRT Standards of Ethics will be provided to me upon my request and can also be found on the ARRT website at
www.arrt.org.
By signing this document and filing it with the ARRT, I understand that ARRT may confirm the information contained in the
Ethics Review Pre-Application and may also request information related to my education, training, employment, and personal
history including, but not limited to, a criminal background check. I hereby certify that the information given in this Ethics Review
Pre-Application is true, correct, and complete, and that I have read and accept the terms and conditions, and agree to be
legally bound by and to abide by all the terms and conditions set forth in this Ethics Review Pre-Application agreement and
ARRT’s Rules and Regulations and Standards of Ethics.
I understand and agree that information submitted through this Ethics Review Pre-Application may be used to initiate
disciplinary action under ARRT’s Rules and Regulations and Standards of Ethics and that such action may result in an
ARRT sanction.
I understand and agree that any misrepresentation in this Ethics Review Pre-Application or in any other document or other
information I submit to ARRT (including the verification of my identity when I submit this Ethics Review Pre-Application), or any
offer of financial benefit to an ARRT Trustee, committee member, employee, or other agent or representative of the ARRT in
order to obtain a right, privilege, or benefit not usually granted by the ARRT to similarly situated individuals, is grounds for
ARRT to bar me permanently from certification and registration, and that ARRT’s decision on any such matter is final.
I hereby waive and release, shall indemnify and hold harmless, ARRT and persons in their capacities as ARRT Trustees,
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) that arise or are alleged to have arisen from, out of, with
respect to, or in connection with any action which they or any of them take or fail to take as a result of or in connection with this
Ethics Review Pre-Application, and ARRT’s notification of legitimately interested persons of such actions taken by ARRT.
I understand and agree that in the event of my breach of or default in any provisions of this Ethics Review Pre-Application
agreement in any respect whatsoever, ARRT shall have the absolute right, in its sole discretion, to deny my eligibility for
certification and registration.
Signature of Applicant Date
Before me personally appeared
to me known to be the person described in this Ethics Review Pre-Application,
who signed the foregoing instrument in my presence, and made oath before me
to the accuracy of the standards set forth therein on,
Notary to check
if no seal
the
day of
, 20
.
is required
Notary Public Signature (NO SIGNATURE STAMPS)
My commission expires
Complete Front and Back of Form
Rev. 12/2014
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