Practice Readiness Assessment: Assessor Application & Practice Profile

Are you interested in becoming a PCA assessor for CPSA’s Practice Readiness Assessments? Complete your application below.

For Practice Readiness Assessments

CPSA Registration Number*
Name*
First Last
Email*
Enter Email Confirm Email
Practice/Clinic Name*
Practice/Clinic Mailing Address*
Street Address Address Line 2 City Province Postal Code
Current registration in:*
- Family medicine
- Speciality practice
If you selected "speciality practice," please specify:*
Practice description*
- Clinic Group Practice
- Clinic Solo Practice
- Emergency Department
- Acute In-Patient
- Long-Term-Care In-Patient
- I do not work in a hospital
Do you practice low-risk obstetrics?*
- Yes
- No
Do you provide antenatal and postpartum care?*
- Yes
- No
Do you have a faculty appointment?*
- Yes
- No
Does your current clinic allow you to take on PRA applicants?*
- Yes
- No
Do you have experience performing assessments?*
- Yes
- No
Please indicate the type of assessments you have performed:*
Why are you interested in performing Practice Readiness Assessments for CPSA?*
Please provide 3 references for CPSA to contact:*
Please click the "+" to add references.
Full name Phone number Email
Comments
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