Fillable Neurodiagnostics Application to Interpret Evoked Potentials (EP) (College of Physicians & Surgeons of Alberta)

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Neurodiagnostics Application to Interpret Evoked Potentials (EP) (College of Physicians & Surgeons of Alberta)

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The Neurodiagnostics Application to Interpret Evoked Potentials (EP) (College of Physicians & Surgeons of Alberta) form is 2 pages long and contains:

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  • 11 check-boxes
  • 45 other fields

Country of origin: CANADA
File type: PDF

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Neurodiagnostics –
Application to Interpret
Evoked Potentials (EP)
1 A
pplication to Interpret – Evoked Potentials (EP)
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 applying for: Interpreter (10 EP studies per year with evidence of acceptable training)
Director (Current Approval to Interpret)
2. I am a specialist in:
Neurology (adult or pediatric)
Neurosurgery
Otolaryngology
Ophthalmology
Physical Medicine and Rehabilitation
Pediatrics (with extra training in Neurology, suitable to Council)
3. I am applying for approval to interpret the following Evoked Potentials:
Visual Auditory Sematosensory
4. My training is as follows:
Institution
Dates
From (Month/Year)
To (Month/Year)
Neurodiagnostics –
Application to Interpret
Evoked Potentials (EP)
2 A
pplication to Interpret – Evoked Potentials (EP)
5. I have enclosed a letter confirming training and competence from the program provider.
(Note: This evidence of training and competence is required.) Yes No
6. M
y experience is as follows:
Institution
Dates
From (Month/Year)
To (Month/Year)
7. E
xpected Practice Start Date: ________________________________________
P
rivacy Notice: The College of Physicians & Surgeons of Alberta collects, uses and/or discloses your person
al
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.
A
pplicant Signature: ________________________________ Date: _____________________________
P
lease 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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Neurodiagnostics Application to Interpret Evoked Potentials (EP) (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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