LXMO Examination Application for Practice in Radiography · Obtain a signed and dated course...

(For Office Use Only)

Deposit No.

Date Entered Into ARRT Exam OBMI No.

Revised 01.16.2020 of 4

OREGON BOARD OF MEDICAL IMAGING 800 NE Oregon Street – Suite 1160A

Portland, OR 97232-2162 Phone: (971) 673-0215 / Fax: 971-673-0218

Website: http://www.oregon.gov/OBMI Email: [email protected]

STAPLE APPLICANT’S PHOTOGRAPH

HERE

A Photocopied Picture Will NOT Be Accepted

LXMO Examination Application for Practice in Radiography Completely fill out this application after you have completed and passed your classes at one of the OBMI Board Approved Limited Permit X-Ray Machine Operator (LXMO) Schools. You’re Exam Application will not be processed if any of the required information on this form is incomplete or if you haven’t Attached a Course Completion Certificate to this application. All applicants “MUST” take the core exam.

Mark (X) all of the exams that you are paying for and wish to take:

Core Exam ($20.00) Chest Exam ($20.00) Extremities Exam ($20.00)

Skull Exam ($20.00) Spine Exam ($20.00) Podiatry Exam ($20.00)

There is a $140.00 Exam Fee every time you sign up to take an ARRT Exam. Each separate exam is an additional $20.00.

Enter the number of exams being taken ____ x $20.00 (each) + $140.00 Exam Fee = $______.____. OBMI will only accept Money Orders, Cashier’s Checks or Company Checks for Exam Payment.

(Cash or Personal Checks are not accepted for Exams.) Incomplete information, including necessary documents and funds will delay your permit. Allow 5- Working Days for processing.

Part 1: About You.

Last Name: First Name: Middle Name: Other Last / Maiden Names You’ve Used:

Ethnic Background: Gender:

Date of Birth: Height: Weight: Hair Color: Eye Color:

Social Security No. (Mandatory) Driver’s License No. State Issued In:

Part 2: Contact Information

Mailing Address (Or P.O. Box):

City: State: Zip-Code

Cell Phone No. Home Phone No. Home Email Address:

Work Email Address:

(Protected From Release Unless Legally Compelled)

Part 3: Where Did You Get Your Education? What School or Facility did you attend to get Your Medical Imaging Education? Mailing Address of College/School: City State: Zip-Code: Contact Person From That College/School:

College/School Phone No:

Graduation Date:

Part 4: Employer Information List Your Oregon Employer’s (or Prospective) Name: (If you don’t have an employer write “N/A” then go to Part 5.)

Work Address: City: State: Zip-Code:

Supervisor’s Name: Supervisor’s Title: Your Start Date (If Applicable):

Employers Phone No: Date Application Was Received

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Part 5: What You Can Expect After Applying:

You should receive in the mail within a week, a “Limited Scope (LXMO) Candidate Status Report”, and an Exam Handbook from ARRT.

Part 6: Agreement: I understand by signing and submitting this application and my payment do not guarantee admission to the test. I also understand that if I am caught cheating during any examination that I will not longer by eligible to sit for any future ARRT examinations.

By also signing and submitting this form I understand the following:

1.) I HAVE (1-YEAR STUDENT STATUS) from completion of my Limited X-Ray Machine Operator Course (LXMO) 2.) I need to pass the applicable LXMO Exams (which is the “CORE MODULE” and at least ONE ANATOMICAL AREA). 3.) Then I can apply for a TEMPORARY LXMO PERMIT which is needed to complete all applicable Practical Experience. 4.) After completion of steps 1 through 3 then I can apply for a PERMANENT LXMO PERMIT.

Also In consideration of my receiving a permanent license from the Oregon Board of Medical Imaging, I do hereby agree to abide by Oregon laws and administration rules pertain to the practice of Medical Imaging. (ORS 688.405 to 688.605; ORS 688.915 to 688:990; OAR Chapter 337.)

I AM AWARE THAT IF ANY CHANGES OCCUR IN MY EMPLOYMENT AND/OR HOME ADDRESS AND PHONE NUMBER, THE BOARD MUST BE NOTIFIED. I UNDERSTAND THAT AN ONLINE UPDATED INFORMATION FORM IS AVAILABLE ONLINE AT THE FOLLOWING WEBSITE ADDRESS: http://www.oregon.gov/OBMI/

By signing this application below I certify that the information appearing on this application is accurate and true to the best of my knowledge.

___________________________________________________ _____________________________________ Signature of Applicant: Date:

ALL APPLICATION FEES ARE NON-REFUNDABLE Allow 5- Working Days for Processing

Mail Complete Application and Exam Fee to “OBMI”: OBMI – 800 NE Oregon Street, Suite 1160A – Portland, OR 97232

If you need help filling out this application or have questions – please call us at: 971-673-0215 Or email us at: [email protected] with your questions.

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- OBMI Exam Application Checklist -

Before Mailing Your Exam Application Please Check To See If You Remembered All the Required Documents.

Exam Application.

A Color Photograph (2” x 2”).

A Photocopy of Your Course Completion Certificate.

The Correct Exam Fee.

A Money Order, Cashier’s Check, or Company Check. (Sorry! No Cash or Personal Checks Accepted For Exams.)

OREGON BOARD OF MEDICAL IMAGING STARTING SEPT. 1, 2018 -- STEPS TO OBTAIN A PERMANENT LIMITED X-RAY PERMIT

1. Complete a limited x-ray course of instruction that is recognized by the Oregon Board of Medical Imaging.Obtain a signed and dated course completion certificate from the school.

2. Apply for the ARRT exam through the OBMI office. No later than 12 months from the date on your coursecompletion certificate, you must first pass the ARRT CORE exam and then deliver to the OBMI office anapplication for an initial six-month temporary permit in the anatomic areas that you passed in school. (Atany time during that period, you may also sign up for separate exam modules in any anatomic areas thatyou completed in school.)

3. Within twelve months from the date you deliver to OBMI an application for an initial temporary permit, youmust pass the ARRT examination in any anatomic areas you wish to practice in, complete practicalexperience requirements, and deliver to OBMI an application for a permanent permit in those anatomicareas.

4. You can renew an initial six-month temporary permit one time, for a second six-month temporary permit.To renew a temporary permit, the renewal application must be received at the OBMI office no later thanthe date of expiration of the initial temporary permit.

5. Renewal of a temporary permit in an anatomic area is contingent upon having applied for, and sat for, theARRT exam in that anatomic area.

6. Complete practical requirements as specified in the OBMI document entitled “Practical ExperienceEvaluation Requirements” dated July 2018; and

7. Deliver an application for a permanent limited permit to the OBMI office within 12 months of the date thatthe application for an initial temporary permit was delivered to the OBMI.

8. You can only qualify for a permanent limited permit in anatomic areas for which you completed school,passed the ARRT exam with at least a 70% score, and completed practical experience requirements asspecified starting on page 6 of this document.

9. You must deliver to OBMI your application for a permanent permit no later than twelve months from thedate you delivered to OBMI an application for an initial temporary permit, or within seven days from thetime you complete all practical experience requirements, whichever comes first.

10. To add an anatomic area to an existing permanent permit: Once a LXMO permit holder completes anapproved educational program to add an anatomic area to their permanent permit, the applicant mayapply for a temporary permit to complete practical experience requirements in that anatomic area. Theapplicant has one year from the date on the course completion certificate to complete practicalexperience requirements, pass the ARRT examination for that anatomic area, and apply for a permanentpermit in the anatomic area. The applicant is eligible for two six-month temporary permits, which canextend no later than 12 months from course completion. The applicant must have taken the ARRT examto qualify for the second temporary permit. The applicant does not need to pass the CORE exam to addan anatomic area.

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