Neurodiagnostics New Facility Application Form - College of Physicians & Surgeons of Alberta

SECTION 1 - General Facility Information

Facility name(Required)

Address(Required)

Street address Address line 2 City Province Postal Code

Phone number(Required)

Fax number

Email(Required)

Enter email Confirm email

Owner(s)(Required)

Neurodiagnostic testing(Required)

EEG

EMG

EP

Expected opening date/commencement of patient testing (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)(Required)

What are the routine hours of operation?(Required)

If hours of operation vary throughout the week, please click the + to add additional rows.

Day

Hours

SECTION 2 - Personnel

Medical director(Required)

Name

Registration #

Address

Phone number

Email

Consultant 1 (if applicable)

Name

Registration #

Address

Phone number

Email

Approvals

EEG

EMG

EP

Consultant 2 (if applicable)

Name

Registration #

Address

Phone number

Email

Approvals

EEG

EMG

EP

Laboratory supervisor/manager(Required)

Name

Qualifications

Phone number

Email

Assessment contact(Required)

Name

Phone number

Address

Email

Financial contact(Required)

Name

Phone number

Address

Email

Please indicate the number of full-time/part-time and casual staff members

If a field does not apply to your facility, please leave it blank.

Number of EMG technologist

Total

BRETC Certified

AETC Membership

ACMDTT Registration

Number of EEG technologist

Total

BRETC Certified

AETC Membership

ACMDTT Registration

Number of EP technologist

Total

BRETC Certified

AETC Membership

ACMDTT Registration

Submit copies of registration and/or certifications.

Please do not password protect your files.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

SECTION 3 – Service provided

Please describe the service provided. If a field does not apply to your facility, please leave it blank.

EEG

EP

EMG

Visual

Auditory

Somatosensory

SECTION 4 – Interpreters

List of physicians interpreting neurodiagnostic studies in the laboratory.(Required)

Please click the + to add additional rows.

Physician name

Registration #

Approval (EMG, EEG, EP)

SECTION 5 – Required documentation for submission

Organizational structure (e.g. organization chart)(Required)

Please do not password protect your files.

Accepted file types: jpg, gif, png, pdf, docx, , Max. file size: 128 MB.

List of mobile testing locations (if applicable)

Please do not password protect your files.

Accepted file types: jpg, gif, png, pdf, docx, , Max. file size: 128 MB.

SECTION 6 - Equipment

Onsite equipment & maintenance(Required)

Have the relevant calibration records available for the assessment team on the day of the assessment. Please click the + to add additional rows.

Type of equipment (e.g. EMG, EEG, EP equipment that requires quality checks and/or calibration)

Year of manufacture

Serial / Model No.

Date acquired

SECTION 7 - SIGNATURE

Medical director / designate name(Required)

First Last

Date (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)(Required)

Checking this box will act as your signature:(Required)

I have reviewed and confirm that this facility, assessment information and documentation are complete and accurate.

An assessment date will be scheduled once CPSA receives all the necessary information.

This information is being collected under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act (HPA). Alberta’s Personal Information Protection Act protects the confidentiality of these documents. Additionally, we will not disclose any of the above information except as authorized by the HPA and, where applicable, in accordance with section 35(4)(b)(i) of the Health Information Act.

SECTION 1 - General Facility Information

SECTION 2 - Personnel

Please indicate the number of full-time/part-time and casual staff members

SECTION 3 – Service provided

SECTION 4 – Interpreters

SECTION 5 – Required documentation for submission

SECTION 6 - Equipment

SECTION 7 - SIGNATURE

An assessment date will be scheduled once CPSA receives all the necessary information.

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