Fluoroscopy operator forms R-50, R-51 & R-52

Instructions for new applicants, cath lab specialists, renewals, and those retaking the ARRT exam

For questions about completing this form:

Please call 303-692-3448

Email: cdphe.hmxraycomments@state.co.us

Physician assistant and nurse practitioners application category.

New application

Retake ARRT exam

Registration renewal

Please indicate the category for your application *

Physician assistant or nurse practitioner

Cath lab specialist working towards RCIS/RCES/Other approved registration

Cath lab specialist

Cath lab specialist application category.

New application

First renewal

Subsequent renewals

Fluoroscopy operator number

Fluoroscopy operator expiration date +

Please check all that apply:

I am applying using my registration with another state.

Registration state

Payment method

I will make the $60.00 payment via online payment portal. (We will email instructions once your application is submitted. Applications will only be processed after the fee is received via check or money order or verification of payment receipt emailed to unit after submitting online. Fees are non-refundable.) PLEASE NOTE: Additional fees will apply once accepted to test through ARRT. These fees will paid directly to ARRT.

I will mail in a check to: CDPHE, X-Ray Certification Unit, 4300 Cherry Creek Dr. S, Denver, CO 80246.

Applicant information

Enter your first and last name exactly as it appears on the government-issued ID you are bringing to the testing site. The address you enter in this section is where the AART testing packet will be sent.

Applicant's first name

Applicant's last name

Previous legal name/s

Mailing address

City

State

Zip

Primary phone (xxx-xxx-xxxx)

Cell phone (xxx-xxx-xxxx)

Other phone (if applicable) (xxx-xxx-xxxx)

Email

Confirm email

Employer information

Employer/Business name *

Facility registration number

Employer/Business address

Employer city

Employer state

Employer zip

Instruction/education/continuing education affirmation

Instruction/education/continuing education requirement (Colorado Rules and Regulations Pertaining to Radiation Control, 6 CCR 1007-1, Part 2, Appendix 2O, Section 2O.1.1)

The student must complete at least 40 hours of in-person or online instruction/education/continuing education training in the following topics: radiation physics, radiation biology, radiation safety, and radiation management applicable to fluoroscopy.

Name of school or online course

School's street address

School's city

School's state

School's zip

Beginning date +

Ending date +

Educator's name

Educator's phone

Cath lab specialist confirmation of certification

Affirmation of supervision.

I affirm that as a cath lab specialist, I am required to perform my duties only under personal physician's supervision.

Clinical requirement

Name of clinic

Facility registration number

Clinic street address

Clinic city

Clinic state

Clinic zip

Beginning date +

Ending date +

Supervisor's name

Examination module

ARRT Fluoroscopy examination

If you need special accommodations, please review the information on disability accommodations related to ARRT testing.

Required uploads

Documentation of completion of a course that includes at least forty (40) hours of education on topics that include, but are not limited to: radiation physics; radiation biology; radiation safety and radiation management applicable to fluoroscopy. (For PA’S -Certification of successful completion of the didactic component of the latest version of the Fluoroscopy Educational Framework for the Physician Assistant, a program that was developed through collaboration of the American Academy of Physician Assistants and the American Society of Radiologic Technologists, or other education that meets regulatory requirements.)

You can upload up to ten documents with the same upload button.

Documentation of forty (40) clinical hours are required in a clinic under personal supervision by a qualified physician/operator working with living patients. Clinical experience must include the use of fluoroscopy for guidance under the direct supervision of a Colorado licensed physician.

You can upload up to ten documents with the same upload button.

Please upload a copy of your National Certification

Verification of national certification in respective profession, if applicable.

Occupation state license (DORA), if applicable

Instruction/education/continuing education. If you are a Cath Lab Specialist, supporting documentation must be submitted with the renewal form two years from your initial application approval date. A total of 40 hours required.

A signed statement from each individual registrant affirming that they will operate fluoroscopic imaging systems only under the personal supervision of a qualified physician who is present to observe and correct, as needed, the performance of the individual who is performing the examination.

Signature and final affirmation

As a Colorado registered Fluoroscopy Operator, I affirm that I have completed the requirements as outlined in Appendix 2O, Section 2O.1.1 and section 2O 1.2. I also understand that if I do not meet the requirements of Appendix 2O, I will no longer be a Fluoroscopy Operator.

Student affirmation

I certify by my signature below, under penalty of law, this application is prepared in conformity with the Colorado Department of Public Health and Environment’s 6CCR 1007-1 Rules and Regulations pertaining to Radiation Control and that all information contained herein, including any attachments is true, accurate and complete to the best of my knowledge and belief. I understand I must be approved as a Fluoroscopy Operator before independently performing fluoroscopy procedures in the State of Colorado.

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name, title and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.

Applicant signature

Date +