Accreditation Standard Exemption Request Form

Note: CPSA will accept and review standard exemption requests in writing for currently accredited facilities OR new facilities which are in the application phase only.

Requestors will be required to submit requested documentation. CPSA will review for completeness.

CPSA will contact the requestor in writing for additional information or confirming a complete submission.

The completed standard request submission will then be reviewed by the CPSA accreditation department and committee at their next regularly scheduled meeting date.

CPSA will contact the requestor in writing shortly thereafter, advising the outcome of the standard exemption request review.

Standard request information

(General Standard or the individual modality/service/scope specific standard document)
(e.g.: Section IG.1.0 Organization, Management & Personnel - Standard IG.1.12)

Contact information

Medical director name:(Required)
Email:(Required)
MM slash DD slash YYYY

Required documentation

• Signed letter of the standard exemption request with reasons and rationale from the medical director
• Impact assessment to Albertans (quality, safety, access)
• Letters of support from users of the facility health services
• Additional evidence (letter from industry/technical consultant, best practice/current references, industry standards, etc.)

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