New Facility or Modality Accreditation Application Form

Fill out this form if you need accreditation for a new facility or modality

  • Please complete all fields as applicable. If you are applying for remotely interpreted Ultrasound or Echocardiography please refer to the Guidance Document on the Diagnostic Imaging Accreditation webpage.
  • General Facility Information

  • Hours of Operation

  • Date Format: DD dash MM dash YYYY
  • Netcare Access and Provincial Imaging Repository Information

  • Personnel (enter NA if not applicable to this facility)

    Note: Stakeholders, listed below, will receive a request prior to the assessment to complete an on-line survey. Findings from the surveys will be shared with the assessment team to inform assessment activities.
  • NameSpecialtyEmail 
  • NameSpecialtyEmail 
    *Click the + to add an additional person
  • NameSpecialtyEmail 
  • NameEmail 
  • NameSpecialtyEmail 
  • NameModality SpecialtyEmailOn site during business hours (Yes/No) 
    *Click the + to add an additional person
  • NameEmail 
  • NameEmail 
  • NameEmail 
  • *Break down staffing by Full Time, Part Time & Casual
  • *Break down staffing by Full Time, Part Time & Casual
  • *Break down staffing by Sonography Canada, ARDMS, Both or ACMDTT
  • *Break down staffing by RN, LPN or not applicable (NA)
  • Scope of Modalities

    Check the specific imaging examination services you will be providing at the facility, OR Check the new modality you are adding to your existing DI facility
  • Program/ProcessContact NameLocation 
    *Click the + to add additiional programs/processes
  • Records Location (for assessor access and review)

    Please identify the location for each of the following types of records. NOTE: A log detailing the completed staff performance evaluations should be available at each site.
  • Additional forms required to complete this application

  • *This form should be completed by the Facility Medical Director (or delegated executive leadership / accreditation contact) identified below in the Attestation Section.

    Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Accepted file types: jpeg, png, jpg, tiff, pdf.
  • Signature

  • (or delegated executive leadership / accreditation contact)
  • This is the email address we will send a submission confirmation notification to.
  • Date Format: MM slash DD slash YYYY

Questions about filling out this form?

Toll-free: 1-800-561-3899 (in Canada)
Fax: 780-424-5859