New Facility or Modality Accreditation Application Form

Please complete all fields as applicable.
General Facility Information
CPSA Facility Number (if already accredited/known):
Facility Name:*
Address*
Street Address Address Line 2 City Province Postal Code
Phone Number:*
Hours of Operation
What are the routine business hours/days of operation?
Are staff readily available outside of routine imaging business hours (on–call)?
- Yes
- No
What are you applying for?
Note: An accredited facility wising to provide a teleradiology modality MUST apply as a new modality in an existing facility. For example: a) an accredited DI facility provides ultrasound (onsite) but wishes to ALSO provide Tele-US: new modality in an existing facility application. b) an accredited DI facility is providing ultrasound (onsite) but WISHES TO SWITCH from onsite US to Tele-US: Notification of Change form to be filled out AND a new modality application in an existing facility application .
- A New Facility
- A New Modality in an existing facility
What is the expected start date? (MM/DD/YYYY)
Netcare Access and Provincial Imaging Repository Information
Select the status for Netcare access:
Select the status for Provincial Image Repository access:
Select the status for Connect Care access:

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Personnel (enter NA if not applicable to this facility)
Note: Stakeholders, listed below, will receive a request prior to the assessment to complete an online survey. Findings from the survey will be shared with the assessment team to inform assessment activities.
Facility DI Medical Director or designated executive leadership (where applicable):*
Name Specialty Email
DI Department Manager / Supervisor / Lead Technologist:
Name Specialty Email
List all imaging specialists that supervise and report for the DI facility/department:
Name Modality Specialty Email On site during business hours (Yes/No - provide explanation)

*Click the + to add an additional person
Number of Technologists (MRT) registered with ACMDTT:
Full Time Part Time Casual
Number of Technologists (CLXT) registered with AACLXT:
Full Time Part Time Casual
Number of Sonographers:
Sonography Canada ARDMS Certified in both Voluntary ACMDTT
Number of Nursing or DI Technical Aides:
RN LPN Aides N/A
Supporting Programs, Processes or Positions
Infection Prevention and Control Lead
Contact Name Located On or Off-Site
PACS/IT
Contact Name Located On or Off-Site
Safety Committee
Contact Name Located On or Off-Site
Radiation Safety Officer
Contact Name Located On or Off-Site
Quality Manager
Contact Name Located On or Off-Site
Equipment and Maintenance Personnel
Contact Name Located On or Off-Site
Facility Accreditation Contact
Identify the singular person who will be responsible for coordinating the assessment logistics. They will be granted access to the secure CPSA Facility Accreditation SharePoint site, and will be the primary contact throughout the accreditation process.
Facility Accreditation Contact:*
Name Title Email Phone

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Records Location (for assessor access and review)
Please identify the location for each of the following types of records (documents, policies, logs, files, etc.). NOTE: A log detailing the completed staff performance evaluations should be available at each site.
Organization, Management & Personnel
Identify the location of the off-site Organization, Management & Personnel records*
Quality Management System
Documented quality policies, processes and procedures
Identify the location of the off-site Quality Management System records*
Physical Facilities
Identify the location of the off-site Physical Facilities records*
Equipment, Consumables & Supplies
Identify the location of the off-site Equipment, Consumables & Supplies records*
Diagnostic Imaging Information Systems
Identify the location of the off-site Diagnostic Imaging Information Systems records*
Pre-Imaging
Identify the location of the off-site Pre-Imaging records*
Imaging
Identify the location of the off-site Imaging records*
Post-Imaging
Identify the location of the off-site Post-Imaging records*
Quality Assurance of Imaging Exams
Identify the location of the off-site Quality Assurance of Imaging Exams records*
Safety
Identify the location of the off-site Safety records*
Infection Prevention & Control
Identify the location of the off-site Infection Prevention & Control records*
Signature
Checking this box will act as your signature:*
I have reviewed the information in this form and confirm it is accurate.
Name of Facility Medical Director:*
(or delegated executive leadership / accreditation contact)
Email*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email
Date (MM/DD/YYYY)*
Additional notes/comments
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 5

General Facility Information

Hours of Operation

Netcare Access and Provincial Imaging Repository Information

Personnel (enter NA if not applicable to this facility)

Supporting Programs, Processes or Positions

Facility Accreditation Contact

Scope of Modalities

Supplementary Modality Processes

Already accredited? Scope of Modalities for an Existing Facility: Part 1

Scope of Modalities for a New Facility or new modality to an Existing Facility: Part 2

Supplementary Modality Processes

Records Location (for assessor access and review)

Signature

Designated Radiation Equipment

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Name	Modality Specialty	Email	On site during business hours (Yes/No - provide explanation)

Contact Name	Located On or Off-Site

Contact Name	Located On or Off-Site

Contact Name	Located On or Off-Site

Contact Name	Located On or Off-Site