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Instructions for Completing Verification of Professional Experience, Form 4A

NOTE: Send these instructions to your endorser with Form 4A.

These instructions are intended to assist the applicant and the qualified individual (employer, supervisor, professional colleague) who intends to serve as the endorser validating the applicant's professional experience to meet the requirements for licensure as a medical physicist in New York State. If there are any questions about these guidelines, or any other aspect of licensure in medical physics, please feel free to contact the Office of the Professions, Medical Physicist Unit at opunit2@nysed.gov or call 518-474-3817 ext. 260 or contact the State Committee for Medical Physics at medphysbd@nysed.gov or call 518-474-3817, ext. 560 or write to:

The State Committee for Medical Physics
89 Washington Avenue, Second Floor
Albany, New York 12234-1000.

Both the applicant and the endorser should read and be thoroughly familiar with these instructions. The form used to list professional experience (Form 4) requires a comprehensive listing of all endorsers and places of employment where the applicant gained his/her professional experience as a medical physicist. This form also requires the applicant to identify their particular specialty area within the profession. The specialty area descriptions are defined in statute and listed below.

Professional Specialty Areas

The following descriptions define the four specialty areas that an applicant for licensure in New York State may apply for:

  • Diagnostic radiological physics is the branch of medical physics relating to the diagnostic application of radiation, the analysis and interpretation of image quality, performance measurements and calibration of equipment associated with the production and use of radiation, the analysis and interpretation of measurements associated with patient doses and exposures, and the radiation safety aspects associated with the production and use of such radiation
  • Medical health physics is the branch of medical physics pertaining to the radiation safety aspects of the use of radiation for both diagnostic and therapeutic purposes, and the use of equipment to perform appropriate radiation measurements
  • Medical nuclear physics is the branch of medical physics pertaining to the therapeutic and diagnostic application of radionuclides, excluding those used in sealed sources for therapeutic purposes, the analysis and interpretation of performance measurements associated with radiation imaging equipment and performance oversight of radionuclide calibration equipment associated with the use and production of radionuclides, the analysis and interpretation of measurements and calculations associated with patient organ doses, and the radiation safety aspects associated with the production and use of radionuclides
  • Therapeutic radiological physics or radiation oncology physics is the branch of medical physics relating to the therapeutic application of radiation, the analysis and interpretation of radiation equipment performance measurements and the calibration of equipment associated with the production and use of radiation, the analysis and interpretation of measurements associated with patient doses, and the radiation safety aspects associated with the production and use of radiation

General Instructions for completing Form 4A

All experience submitted by applicants for licensure is initially listed and attested to on Form 4. The applicant should transcribe the professional experience information, including a comprehensive description of their professional experience, from the Form 4 to an individual Form 4A for each endorser. Sufficient detailed information should be provided in order to permit the Department to evaluate the experience and determine its acceptability for licensure.

Instructions for the Applicant: Section I is completed by the applicant. You should indicate:

  • the duration of your experience
  • whether your experience was full or part-time and the number of hours you worked each week if part-time
  • your specialty area and, if more than one specialty area, specifically what percentage of your time was spent in each area. A separate Form 4A must be submitted for each specialty area you are applying for.
  • the total number of clock hours in a calendar year devoted to the specific specialty area in this particular place of employment.

You should sign and date the affidavit attesting to the accuracy of the information on the form.

Instructions for the Endorser: Section II must be completed by the endorser and returned directly to the State Education Department in a sealed, official envelope. Questions 1-5 must be completed along with a description of the endorser's professional licensure status and qualifications for determining that the applicant's experience was professional medical physics. The endorser should sign and date the attestation or indicate that you are unable to do so and include a separate letter of explanation.