Diagnostic Laboratory - Register a New Facility Form - College of Physicians & Surgeons of Alberta

General Facility Information
Hidden
CPSA Facility Number
For CPSA use only.
Hidden
Facility Type
For CPSA use only.
Facility Name*
Address*
Street Address Address Line 2 (Optional) City Province Postal Code
Phone Number*
Facility Ownership/Funding Type*
- Public
- Private
Expected Opening Date/Commencement of Patient Testing (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY
What are the routine hours of operation?*
If hours of operation vary throughout the week, please click the + to add additional rows.
Day Hours
Are staff readily available outside of routine hours (on–call)?*
- Yes
- No

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Personnel
Zone Medical/Laboratory Director*
Name Address Phone Email
Laboratory Director**
*Individual defined in CPSA General Standards G.1.2.3 (not the Administrative Director of the Laboratory) – See Appendix A for standard
Name Address Phone Email
Laboratory Consultant (Specify MD or PhD)
Note: For facilities without on-site pathologists, please list the consultant specialist(s). Click the + to add additional laboratory consultants.
Specialty/discipline Name Address Phone Email
Laboratory Liaison Physician (For hospital-based facilities)
Name Address Phone Email
Laboratory Supervisor (Specify MLT or CLXT)*
Name Phone Email
Please indicate the following as full-time equivalents:
If a field does not apply to your facility, please leave it blank.
Number of Pathologists (On-site full-time)
Number of Clinical Laboratory Doctoral Scientists (CLDS)
Number of Supervisory Technologists (Section Heads)
Number of Technologists (MLT) Other than Supervisors
Number of Technicians (CLXT)
Number of Laboratory Assistants
Number of Clerical Staff
Number of Other (specify)

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Required Documentation for Submission
Organizational Structure (e.g. Organization chart)
Please do not password protect your files.
Accepted file types: jpeg, png, jpg, tiff, pdf, docx, Max. file size: 5 MB.
Example of Examination Request Forms (Initiated from Facility/Zone)
Please do not password protect your files.
Accepted file types: jpeg, png, jpg, tiff, pdf, docx, xlsx, Max. file size: 5 MB.
Example of Patient Reports (1 example for each discipline where applicable)
Please do not password protect your files.
Drop files here or

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.
Analyzer/Instrument List by Lab Section (Including year of purchase)
Please do not password protect your files.
Accepted file types: jpeg, png, jpg, tiff, pdf, docx, xlsx, Max. file size: 5 MB.
Complete List of Examination Procedures Performed in the Laboratory
Please do not password protect your files.
Accepted file types: jpeg, png, jpg, tiff, pdf, docx, xlsx, Max. file size: 5 MB.

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Signature
Name of Laboratory Director/Designate*
First Last
Date (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY
Checking this box will act as your signature:*
I have reviewed the information in this form and confirm it is accurate.
Submitter Information
We will use this information to contact you about the status of your application.
Name (if different than above)
Email*
Enter Email Confirm Email
Privacy Notice: This information is being requested under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act.
Name
This field is for validation purposes and should be left unchanged.

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Diagnostic Laboratory - Register a New Facility

Day	Hours

Specialty/discipline	Name	Address	Phone	Email

Program/Process	Contact Name	Location