Ascension Providence Hospital School Radiology Application

Person to Notify in Case of Emergency
Education and Training
Employment History
Please Read the Following Carefully & Agree or Disagree
I understand the information on this application is subject to check and verification by the Providence Hospital School of Radiologic Technology and the my previous employers may be asked for information regarding my employment with them. I hereby authorize all schools that I have attended, my former employers, my military service brand and any others having information concerning me or my past employment to release in confidence all information regarding me. I hereby release from liability each and all of those who provide such information. I understand that my acceptance into the school of Radiologic Technology is dependent upon my successful completion of a physical examination to be conducted by the hospital.
Technical Standards Survey
The inability to perform any of the listed activities indicates a reduced chance of successful completion of the program, or employment in this profession. In such a case, it is recommended that the student not enter the radiography program.

Please read the following statements identifying the technical standards and answer the question provided below. This form is to be returned by the candidate along with the completed application.

The radiologic technologist must have sufficient strength and motor coordination required to perform the following physical activities:                  

  • Standing or walking during most of the clinical training.
  • Frequent reaching and manual dexterity in handling accessory equipment for diagnostic purposes. (lift a minimum of 30 pounds)
  • Frequently transporting, moving, lifting and transferring patients from a wheelchair or stretcher to and from a radiographic table
  • Possess normal visual and audio acuity. This is necessary to report visual observations of patients and read written orders. Hearing must be adequate to assess patient needs and communicate verbally with other health care providers
  • Possess sufficient verbal and written skills to communicate needs promptly and effectively in English.

Are you able to perform all of the technical standards identified above with or without reasonable accommodation?