Fillable Cardiac Exercise Stress Testing Application to Interpret (College of Physicians & Surgeons of Alberta)

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Cardiac Exercise Stress Testing Application to Interpret (College of Physicians & Surgeons of Alberta)

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Cardiac Exercise Stress Testing
Application to Interpret
1 Application to Interpret – Cardiac Exercise Stress Testing
APPLICANT INFORMATION (Please Print)
CPSA Registration Number: ____________________________
Last Name: ___________________________________________ Given/First Names: __________________________
Street Address: __________________________________________________________________________________
City: _______________________________________________ Postal Code: ________________________________
Telephone Number: (______) ____________________________ Fax Number: (______) _______________________
E-mail Address: _________________________________
1. I am a specialist in: Cardiology Other: ______________________________
I am applying for: Director Interpreter
Does testing include pharmacological stress testing? Yes No
• Evidence of training and/or experience with this technique.
(Cardiologists may proceed to # 4)
2. If not a Cardiologist, please review the required experience and training:
Medical Director Interpreter
CEST
Qualified and approved by the College to
supervise and interpret cardiac exercise
stress testing.
Be approved by the College to interpret
ECG’s.
Current ACLS certification.
Minimum two weeks full-time participation
with direct involvement in 100 CEST studies,
under the supervision of a specialist in
cardiology or a specialist in internal medicine
with a faculty appointment.
3. My training in cardiac stress testing is as follows:
Institution
Dates
From (Month/Year)
To (Month/Year)
Cardiac Exercise Stress Testing
Application to Interpret
2 Application to Interpret – Cardiac Exercise Stress Testing
Documents required with this application:
• A copy of current ACLS certification.
• A letter confirming training and competence from the program provider.
• Confirmation of successful completion of ECG exam.
4. My training in cardiac exercise stress testing is as follows:
Institution
Dates
From (Month/Year)
To (Month/Year)
5. Expected Practice Start Date: ________________________________________
Privacy Notice: The College of Physicians & Surgeons of Alberta collects, uses and/or discloses your personal
information with your consent or as authorized or required by law and in accordance with our Privacy
Statement. We collect and use your personal information in order to support the business of the College,
specifically protect the public and to guide and regulate our members.
Applicant Signature: ________________________________ Date: _____________________________
Please return your completed application and required documents (together as one package) to the
College of Physicians & Surgeons of Alberta by fax: 780-428-2712 or by mail:
2700 - 10020 100 ST NW, Edmonton AB T5J 0N3
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Cardiac Exercise Stress Testing Application to Interpret (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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