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Service Provider for Health Monitoring

Are you applying for:(Required)

Applicant information

Name(Required)
Address(Required)
Email(Required)
Does the Individual or monitoring team include at least one CPSA regulated professional, in good standing, with the relevant scope of practice?(Required)
Are you committed to adhering to all relevant CPSA Standards of Practice, as well as the Canadian Medical Association (CMA) Code of Ethics and Professionalism?(Required)
Are you committed to adhering to the 2019 Federation of State Physician Health Program (FSPHP) guidelines, and to discussing with CPSA in advance the rationale for any material deviation?(Required)
Are you committed to adhering to fitness-to-work principles as outlined in the American College of Occupational and Environmental Medicine (ACOEM) or reasonable alternative guidelines for fitness determinations in safety-sensitive settings, including the impact of medications and substances?(Required)
Do you have access to relevant expertise/experience in Occupational Medicine that is acceptable to CPSA?(Required)
Do you have access to relevant expertise/experience in Mental Health that is acceptable to CPSA?(Required)
Do you have access to relevant expertise/experience in determining fitness for duty in safety-sensitive occupations, that is acceptable to CPSA?(Required)
Do you have experience working with legal counsel/patient advocates?(Required)
Please check all characteristics that best describe the individual or team applying to become a service provider for Health Monitoring:(Required)
Health monitoring should not be performed by the service provider that conducted the initial fitness to practice (IME). The service provider can provide both services, but not for the same regulated member. Do you identify any conflicts of interest?(Required)
Do you agree to report to CPSA any monitored member’s non-compliance (including but not limited to missed clinical interviews, non-compliance with diagnostic, therapeutic and other components of a monitoring agreement) without delay, and as soon as reasonably possible?(Required)

Signature

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