Radiation Therapy Program Clinical Education

This form is completed by a representative of the clinical site — a manager, supervisor, or lead therapist. Students do not complete this form. Your answers save in this browser as you go, so you can close the page and come back.

Washburn internal notes — not for the clinical site Nothing to do here — please skip ahead

These points are generated automatically from your answers below, so the program coordinator can see what needs follow-up. They update as you fill out the form.

Date completed

Section 1 · Facility and Supervisor

Facility name

Street address

City

State

ZIP

Department phone

Department supervisor

This is the person Washburn lists as the department administrator. Enter the name in parts so it transfers cleanly to the accreditation portal.

Title

First name

Middle

Last name

Phone

Add the supervisor to program email updates (monthly bulletins, preceptor notices, calendar changes)?

Yes No

Section 2 · Clinical Preceptor

Name one registered radiation therapist with at least two years of experience to serve as Clinical Preceptor. This person should have experience mentoring students, or continuing education in teaching and learning. If the preceptor is also the supervisor, repeat the name here — the accreditation portal records the two roles separately.

Title

First name

Middle

Last name

Degree

Credentials

Years of experience

Phone

Two things we need from the preceptor:
1. Complete the CV form at wu-radiation-therapy-faqs.netlify.app/preceptor-cv
2. Confirm the ARRT credential is current. You can look it up at arrt.org/pages/verify-credentials — no need to send us a copy if the name and credential above match the registry.

Backup preceptor (optional)

Someone who can sign off on competencies when the primary preceptor is out.

Name

Section 3 · Accreditation

Which of these apply to your facility? Check all that apply.

Accreditation expires

If the certificate has no expiration date, enter the issue date.

Document needed: a letter, certificate, or portal printout showing current accreditation or radiation-safety compliance. Any file type is fine — PDF, Word, or a photo of the certificate. Please put your facility name in the filename so it does not get lost, then upload it with this questionnaire using the link in the last section. If you cannot find the certificate, the last section lists where to look it up online.

Section 4 · Staffing

Question	Response
How many licensed radiation oncologists?
Is a radiation oncologist on site daily?	Yes No
How many registered radiation therapists?
How many certified medical dosimetrists on site?
How many certified medical physicists?
How is medical physics support provided?
Is the nursing staff willing to teach students the nursing duties they need to observe and document — patient consults, on-treatment visits, and patient care competencies?	Yes No

Section 5 · Dosimetry Rotation

Every student completes a short dosimetry rotation, usually two to four weeks, and must calculate six treatment plans to meet ARRT requirements. This section decides whether a placement at your site can work, so please answer it before anything else.

Is there a dosimetrist on site who could supervise a two to four week student dosimetry rotation?

Yes No

If no dosimetrist is on site, which of these could your site support? Check all that apply.

An on-site physicist teaches the dosimetry rotation A dosimetrist can come on site for the rotation period A remote dosimetrist teaches by screen share, with the student on site at a planning station None of these are possible

Stop here and contact us before you submit. Without a workable dosimetry rotation we most likely cannot affiliate, because students cannot meet the ARRT dosimetry requirement at your site. There may still be an option we can build together, so email Sean Conrad at Sean.Conrad@Washburn.edu before finishing this form.

Before you check this box

Please talk with the dosimetrist or physicist who would take the student. Teaching a rotation is different from having one on the schedule — it means sitting with a student at the planning station, walking through calculations, and letting them work hands-on in the system.

I have had this conversation, and the person who would take the student has agreed to teach the rotation.

Anything else we should know about how dosimetry would work at your site?

Section 6 · Other Programs Using Your Department

Accreditation standards set clinical capacity at one student per linear accelerator at any one time, counting students from every program that uses your department. A site with two linacs can host two students total, across all schools.

Is your facility currently affiliated with another radiation therapy program?

Yes No

Which programs

Section 7 · Equipment

Number of linacs

Manufacturer and model

Student capacity at any one time

— one per linac, across all programs

Number of simulators

Treatment planning system

Patients treated per machine per day

We require an average of at least 20 patients per machine per day. Students build setup speed and muscle memory through repetition, with as little downtime as possible, and below that average there is not enough volume to get them there. If your current average is under 20, we are not able to affiliate yet.

Your average is below 20 per machine per day, so we cannot affiliate right now. There is no need to finish the rest of this form — please don't spend the time. When your volume reaches the minimum, come back and start fresh, and we will pick it up from there. If you think the number here is off, or your volume is about to change, email Sean.Conrad@Washburn.edu and we will take a look.

Imaging and delivery techniques available

Check what your department uses routinely.

Is anything planned in the next year that could disrupt a student rotation?

Construction, a unit swap, extended downtime, a move, or a service change. If nothing is planned, leave this blank.

Section 8 · Brachytherapy

Brachytherapy is one of the seven participatory competencies every student must complete. Participatory means the student takes an active role and understands the concepts behind the procedure — it does not require them to deliver treatment.

Does your facility perform brachytherapy?

HDR LDR Not performed here

If brachytherapy is not performed, could the student still meet the competency through a lab exercise at your site?

A lab exercise using applicators, afterloader training equipment, a vendor demo unit, or a walkthrough with your physicist all count. If any of that is possible, answer Yes.

Can a brachytherapy lab exercise be arranged on site?

Yes No

If neither is possible, the student travels to another facility we are already affiliated with that performs brachytherapy. We arrange that, but the student should know travel may be required. Our current affiliates are listed at washburn.edu — active affiliates.

Section 9 · Student Clinical Experience

These questions map to the ARRT Radiation Therapy Didactic and Clinical Competency Requirements effective February 2027, which our students follow.

What hosting a student involves

Students rotate through clerical, nursing, treatment, simulation, brachytherapy, dosimetry, and quality control.
Students are not staff. They are never counted in staffing decisions and never fill a vacancy.
Clinical hours are unpaid.
Staff are willing to teach, and to let students take a hands-on role under supervision.

Our administration and staff understand and agree to all of the above.

Participatory competencies

Students must participate in seven procedures that are critical but not always common. Brachytherapy is the seventh and was covered in Section 8. ARRT allows any of these to be completed as a simulated clinical lab exercise if the procedure is not available on a patient. If a lab exercise is possible at your site, check the box.

Total body irradiationPerformed on patients, or possible as a simulated lab exercise Craniospinal treatmentPerformed on patients, or possible as a simulated lab exercise Stereotactic treatment — SRS, SRT, or SBRTPerformed on patients, or possible as a simulated lab exercise Motion management — surface guidance, gating, fiducial tracking, breath hold, or abdominal compressionPerformed on patients, or possible as a simulated lab exercise Special simulation procedure — 4D CT, SBRT sim, gated sim, or brachytherapy simPerformed on patients, or possible as a simulated lab exercise Custom block process, photon or electronCheck this if you order from a vendor such as .decimal, design electron cutouts, shape fields with MLC, or can run it as a simulated lab exercise. Cutting blocks in house is not required.

Leave a box unchecked if the procedure is neither performed at your site nor possible as a lab exercise. That is useful for us to know — it is not a disqualifier on its own.

Quality control

Can a student take part in routine QC on the linac and simulator — laser alignment, imaging systems, beam output and symmetry, and the water phantom check?

Yes No

Treatment procedures

Students complete 16 treatment procedures. ARRT requires 13 of those on patients and allows no more than three to be simulated, so case variety matters. We are not asking you to count cases — just flag anything below that your department rarely or never treats.

Procedures your department rarely or never sees

Radiation monitoring

Under the affiliation agreement, the clinical site provides each student a radiation detection badge and reviews the report with them on your collection schedule.

Badge collection interval

Can students be given online access to their own dose reports?

Yes No

Your radiation safety officer can usually request student logins from the badge vendor, which saves everyone the monthly paper chase.

Section 10 · Additional Rotation Locations

Our program runs twelve months and moves fast, so we keep each student at one location whenever we can. A student who splits time between buildings loses continuity with their preceptor and their patients.

Would a student need to rotate to any other location — a satellite clinic, a second campus, or another building in your system?

Yes No

Let's talk before you submit. Every physical location where a student provides care has to be separately affiliated and approved, and the program pays a fee per site that needs budget approval ahead of time. Email Sean.Conrad@Washburn.edu and we will work out whether the second location is necessary or whether the rotation can be built around it.

Name, address, and phone for each additional location

Roughly how many days there

Section 11 · Affiliation Agreement Contact

Once we review this questionnaire we send the affiliation agreement for signature. Tell us who handles contracts at your facility — often legal, contracts, or an administrator rather than the department.

Name and title

Anything else we should know about your facility or this placement?

Section 12 · Sending This Back

Save this form to your computer

Use the button below. In the print dialog choose "Save as PDF" as the destination rather than a printer. Your facility name is filled into the filename automatically — please keep it there so we can match the form to your site.

Open the upload folder

The second button opens a Washburn folder. You do not need an account to upload.

Enter a name when SharePoint asks, then upload both files

Once you click Upload, SharePoint asks for a first and last name before it will accept anything. Feel free to put your site name there instead of your own, split across the two boxes however works best. Your city and state are already built into the saved filename, so there is no need to repeat them. Nothing is sent when you save the form; this upload step is what delivers it to us.

Step 1, then step 2 Upload the PDF

Heads up: after you click Upload, SharePoint will ask for a first and last name. Feel free to enter your site name there instead of your own — we don't need yours, it is just something OneDrive requires before it will accept files. Split it across the two boxes however works best. For example, Radiation Cancer Center could go in as first name Radiation, last name CC. Whatever you enter gets attached to the front of every file you upload, which is exactly how we want them labeled.

Upload button not working? Some hospital networks block outside file-sharing sites, and share links can expire. Either way you are not stuck — email your saved form and accreditation document to Sean.Conrad@Washburn.edu and we will take it from there.

What we need in the folder

This questionnaire, saved with your facility name in the filename

Current accreditation letter, certificate, or portal printout — any file type

Clinical Preceptor CV — completed at the CV form

Don't have the accreditation certificate handy? Most accreditors publish a public lookup. Search your facility, then print the result page to PDF or take a screenshot — that works as proof for our records.

The Joint Commission — qualitycheck.org. Search by name or city; accredited organizations show the Gold Seal, and you can download a Quality Report.
DNV Healthcare — certificatechecker.dnv.com. Filter by state or accreditation type.
ACR — Accredited Facility Search. Covers radiation oncology and all other modalities, including applications in progress.
AAAHC — Find Accredited Organizations.
State license or linac registration — your state radiation control program issues these. Many states post a searchable registry; your RSO or physicist usually has the current certificate on file.
ACHC and ACRO — no public directory. Your quality or accreditation office can send you the certificate.

Sean Conrad · Sean.Conrad@Washburn.edu

Clinical Education Coordinator · Radiation Therapy Program · Washburn University

Radiation Therapy Program Clinical Education

Clinical Education

Clinical Affiliate Questionnaire

These points are generated automatically from your answers below, so the program coordinator can see what needs follow-up. They update as you fill out the form.

Program use — summary

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