{"id":621,"date":"2025-01-27T17:38:59","date_gmt":"2025-01-28T01:38:59","guid":{"rendered":"https:\/\/forms.bellevuecollege.edu\/imaging\/?page_id=621"},"modified":"2026-05-04T11:12:59","modified_gmt":"2026-05-04T18:12:59","slug":"radiation-dosimeter-form","status":"publish","type":"page","link":"https:\/\/forms.bellevuecollege.edu\/imaging\/radiation-dosimeter-form\/","title":{"rendered":"Radiation Dosimeter Form"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Many students in our educational programs are required to obtain a radiation dosimeter through the Radiation Safety Program. Please verify the requirements of your individual program prior to completing this form.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This form is to\u00a0be completed at least 8 weeks prior to your scheduled clinical practicum. If you do not yet have a site, complete the form as if you will need a dosimeter and notify us of your situation at Krystal.Johnson@bellevuecollege.edu right away.\u00a0<\/p>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_96' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Radiation Dosimeter Acknowledgement<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_96'  action='\/imaging\/wp-json\/wp\/v2\/pages\/621' data-formid='96' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_96' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_96_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_96_3'>\n                            \n                            <span id='input_96_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_96_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_96_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_96_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_96_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_96_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_96_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_5'><span class='gform-field-label__text'>ctcLink ID<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_96_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_6'><span class='gform-field-label__text'>Bellevue College Program<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_96_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Radiologic Technology, AA (RATEC)' >Radiologic Technology, AA (RATEC)<\/option><option value='Radiation Therapy, AA (RADON)' >Radiation Therapy, AA (RADON)<\/option><option value='Nuclear Medicine, AA (NMTEC)' >Nuclear Medicine, AA (NMTEC)<\/option><option value='Radiation &amp; Imaging Sciences, BAS &amp; Certificates (RAIS)' >Radiation &amp; Imaging Sciences, BAS &amp; Certificates (RAIS)<\/option><option value='Medical Dosimetry (DOSM)' >Medical Dosimetry (DOSM)<\/option><\/select><\/div><\/div><div id=\"field_96_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Student Contract<\/h3><\/div><fieldset id=\"field_96_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acknowledgement 1<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_96_7'><div class='gchoice gchoice_96_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='I acknowledge that I must return my radiation dosimeter to Bellevue College within 5 business days of the completion of the calendar quarter either in person at T208 or by mail.'  id='choice_96_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_96_7_1' id='label_96_7_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I must return my radiation dosimeter to Bellevue College within 5 business days of the completion of the calendar quarter either in person at T208 or by mail.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_96_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acknowledgement 2<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_96_9'><div class='gchoice gchoice_96_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='I acknowledge that I will be responsible for a $25 fee if I lose or fail to return my dosimeter.'  id='choice_96_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_96_9_1' id='label_96_9_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I will be responsible for a $25 fee if I lose or fail to return my dosimeter.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_96_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acknowledgement 3<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_96_10'><div class='gchoice gchoice_96_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='I acknowledge that I  must put &#039;do not x-ray; radiation monitor inside&#039; on my return envelope if I return my dosimeter by mail'  id='choice_96_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_96_10_1' id='label_96_10_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I  must put &#8216;do not x-ray; radiation monitor inside&#8217; on my return envelope if I return my dosimeter by mail<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_96_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acknowledgement 4<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_96_11'><div class='gchoice gchoice_96_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='I acknowledge that the contact information on this form, including the address below, will be used to mail my radiation dosimeter and my final dosimeter report, and I have verified that it is correct.'  id='choice_96_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_96_11_1' id='label_96_11_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that the contact information on this form, including the address below, will be used to mail my radiation dosimeter and my final dosimeter report, and I have verified that it is correct.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_96_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dosimeter\/Results Mailing Address<\/h3><\/div><fieldset id=\"field_96_12\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_96_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_96_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_96_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_96_12_1' id='input_96_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_96_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_96_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_96_12_3' id='input_96_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_96_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_96_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_96_12_4' id='input_96_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_96_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_96_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_96_12_5' id='input_96_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_96_12_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_96_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Previous Radiation Exposure<\/h3><\/div><div id=\"field_96_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_19'><span class='gform-field-label__text'>Previous Institution I<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_96_19' type='text' value='' class='large'    placeholder='Institution Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_22'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_96_22' type='text' value='' class='large'    placeholder='Institution Address'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_24'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_96_24' type='text' value='' class='large'    placeholder='Dates of Employment (mo\/yr)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_25'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_96_25' type='text' value='' class='large'    placeholder='Radiation Safety Officer Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_26'><span class='gform-field-label__text'>Previous Institution II<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_96_26' type='text' value='' class='large'    placeholder='Institution Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_27'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_96_27' type='text' value='' class='large'    placeholder='Institution Address'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_28'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_96_28' type='text' value='' class='large'    placeholder='Dates of Employment (mo\/yr)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_29'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_96_29' type='text' value='' class='large'    placeholder='Radiation Safety Officer Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_30'><span class='gform-field-label__text'>Previous Institution III<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_96_30' type='text' value='' class='large'    placeholder='Institution Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_31'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_96_31' type='text' value='' class='large'    placeholder='Institution Address'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_32'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_96_32' type='text' value='' class='large'    placeholder='Dates of Employment (mo\/yr)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_33'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_96_33' type='text' value='' class='large'    placeholder='Radiation Safety Officer Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_34'><span class='gform-field-label__text'>Previous Institution IV<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_96_34' type='text' value='' class='large'    placeholder='Institution Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_35'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_96_35' type='text' value='' class='large'    placeholder='Institution Address'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_36'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_96_36' type='text' value='' class='large'    placeholder='Dates of Employment (mo\/yr)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_96_37'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_96_37' type='text' value='' class='large'    placeholder='Radiation Safety Officer Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_96_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Acceptance<\/h3><\/div><fieldset id=\"field_96_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acknowledgement 4<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div 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for='input_96_40'><span class='gform-field-label__text'>Electronic Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_96_40' type='text' value='' class='large'  aria-describedby=\"gfield_description_96_40\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_96_40'>Please type your full name to illustrate your formal e-signature. By signing, you are articulating that all fields completed above are correct and true.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_96' class='gform_button button btn btn-primary' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_96' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_96' id='gform_theme_96' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_96' id='gform_style_settings_96' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_96' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='96' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='ZSt+qQMhCJW280Sv2c4DzGfPiLq93JZna\/FzA7u2dxfl1S\/x7QmsuQXuSZXS0J2gXjEM0EyS0aF73gOIMkn4VNqeY6w1mMC2+HVdGm2xGLmlrAI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_96' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_96' id='gform_target_page_number_96' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_96' id='gform_source_page_number_96' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>","protected":false},"excerpt":{"rendered":"<p>Many students in our educational programs are required to obtain a radiation dosimeter through the Radiation Safety Program. Please verify the requirements of your individual program prior to completing this form.&nbsp; This form is to\u00a0be completed at least 8 weeks prior to your scheduled clinical practicum. If you do not yet have a site, complete <a class=\"read-more\" href=\"https:\/\/forms.bellevuecollege.edu\/imaging\/radiation-dosimeter-form\/\">...more about Radiation Dosimeter Form<\/a><\/p>\n","protected":false},"author":35731,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-621","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/pages\/621","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/users\/35731"}],"replies":[{"embeddable":true,"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/comments?post=621"}],"version-history":[{"count":2,"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/pages\/621\/revisions"}],"predecessor-version":[{"id":764,"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/pages\/621\/revisions\/764"}],"wp:attachment":[{"href":"https:\/\/forms.bellevuecollege.edu\/imaging\/wp-json\/wp\/v2\/media?parent=621"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}