RADIATION THERAPY TECHNOLOGY PROGRAM
Documentation of Observation Form
For observation at multiple sites, a document of observation form must be submitted from each site.
Copies of this form are acceptable.
PART 1: TO BE COMPLETED BY THE APPLICANT
To the applicant: Upon completion of observation, present this form with a self-addressed stamped
envelope to the radiation therapist who will be providing your documentation of experience. Write
your name and address on the envelope and when it has been returned to you, enclose the
SEALED envelope with the rest of your application materials. (Hand delivery of SEALED envelope
to applicant is acceptable.)
Name ________________________________________ Dates of Observation _____________________
Facility _______________________________________________________________________________
Supervising RadiationTherapist __________________________________________________________
Radiation Therapist Contact Information ___________________________________________________
Total of Number of Days Spent Observing ____________________Total Hours ___________________
________________________________________ ________________________________________
Signature of Applicant Date
PART 2: TO BE COMPLETED BY THE SUPERVISING RADIATION THERAPIST
Please answer the following questions concerning this applicant to the best of your ability.
Your comments will be greatly appreciated.
Applicant Strengths: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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