Return to Practice Assessment Application Form - College of Physicians & Surgeons of Alberta

This assessment helps prepare physicians, previously registered in Alberta, to safely return to practice after an absence of three or more years.

Applicant information

Name of applicant:*

Given name(s) Last name

Email*

Enter Email Confirm Email

CPSA registration #:*

Phone number:*

How many months have you been out of practice in Alberta?*

What was your scope of practice prior to your absence?*

Within the past three (3) years, have you undergone formal training related to your proposed return to practice area?*

Are you planning on taking formal training relating to your proposed return to practice area?*

In your proposed return to practice area will you be practising in a group practice or hospital setting?*

Checking this box will act as your signature:*

I confirm I am the applicant and that information in this form is accurate.

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

For CPSA use only

QUEST Library

Document Type

Document Name

Issuer

Recipient