Fillable Pulmonary Function Diagnostics Application for Physician Approval (College of Physicians & Surgeons of Alberta)

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Pulmonary Function Diagnostics Application for Physician Approval (College of Physicians & Surgeons of Alberta)

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The Pulmonary Function Diagnostics Application for Physician Approval (College of Physicians & Surgeons of Alberta) form is 4 pages long and contains:

  • 1 signature
  • 26 check-boxes
  • 48 other fields

Country of origin: CANADA
File type: PDF

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Pulmonary Function Diagnostics
Application for Physician Approval
| PAGE 1
V1 - JANUARY 2020 APPLICATION FOR APPROVAL TO INTERPRET/DIRECT
© COPYRIGHT 2020 COLLEGE OF PHYSICIANS & SURGEONS OF ALBERTA
Applications/Approval - Interpret Pulmonary Function
APPLICANT INFORMATION (Please Print)
CPSA Registration Number: _______________
Last Name: _________________________ Given/First Names: __________________________
Street Address: ________________________________________________________________
City: _______________________________________________ Postal Code: ______________
Telephone Number: ______________________________
Email Address: _________________________________
1. Degree and Specialty: Respirology (adult or pediatric) Internal Medicine
Anesthesia Pediatrics
2. I am applying for the following: (Complete Appendix A)
Director Interpreter
Level II
Level III
Level IV (Respirologists Only)
3. If not a Respirologist, please review the required experience and training:
Level
Medical Director Interpreter
Level II
One month training in a laboratory
that performs 500 Level III studies
annually.
One month training in a laboratory
that performs 500 Level III studies
annually.
Level III
Six months training in a Level IV
pulmonary function laboratory that
performs 500 studies annually.
Three months training in a laboratory
that performs 500 Level III studies
annually.
Pulmonary Function Diagnostics
Application for Physician Approval
| PAGE 2
V1 - JANUARY 2020 PHYSICIAN APPROVAL APPLICATION
© COPYRIGHT 2020 COLLEGE OF PHYSICIANS & SURGEONS OF ALBERTA
Applications/Approval - Interpret Pulmonary Function
4. My training in pulmonary function testing is as follows:
Institution
Dates
From
(Month/Year)
To
(Month/Year)
4. I have enclosed a letter confirming training and competence from the program
provider: Yes
(Note: Evidence of training and competence must be submitted from your training
Supervisor.)
5. My experience in pulmonary function testing includes:
Institution
Dates
(Month/Year)
To
(Month/Year)
Privacy Notice: CPSA 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 CPSA, specifically protect the public and to guide and regulate our members.
Applicant Signature: ______________________________ Date: _________________
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Pulmonary Function Diagnostics
Application for Physician Approval
| PAGE 3
V1 - JANUARY 2020 PHYSICIAN APPROVAL APPLICATION
© COPYRIGHT 2020 COLLEGE OF PHYSICIANS & SURGEONS OF ALBERTA
Applications/Approval - Interpret Pulmonary Function
APPENDIX A – PULMONARY FUNCTION PROCEDURES
Testing Level
Check those
procedures for
which you are
requesting
approval
Total number of
procedures performed
in the past year.
Numbers must be
provided for request
to be processed.
Level II
Vital capacity (VC)
Timed vital capacity
Forced expiratory volume in the first second (FEV
1
)
(before and after bronchodilator)
Forced vital capacity (FVC) (before and after
bronchodilator)
FEV
1
/FVC (before and after bronchodilator)
Inspiratory & expiratory flow volume loop (before
and after bronchodilator)
Level III
Arterial blood gases/Co-oximetry
Oxygen saturation (pulse oximetry) with quantified
exercise
Lung volumes by gas dilution technique or nitrogen
washout, or body plethysmography
Carbon monoxide diffusion capacity
Non-specific inhalation challenge - methacholine or
histamine
Inspiratory pressure (P
Imax
) and maximal expiratory
pressure (P
Emax
)
Progressive exercise test with two or more workloads
with measurement of heart rate, ventilation and
oximetry
P
ulmonary Function Diagnostics
Application for Physician Approval
| PAGE 4
V1 - JANUARY 2020 PHYSICIAN APPROVAL APPLICATION
© COPYRIGHT 2020 COLLEGE OF PHYSICIANS & SURGEONS OF ALBERTA
Applications/Approval - Interpret Pulmonary Function
Services
Check those
procedures
for which you
are
requesting
approval
Total number of
procedures performed
in the past year.
Numbers must be
provided for
requested to be
processed.
Level IV
Cardio Pulmonary Exercise Testing
In subjects under the age of 5 years: assessment of
pulmonary function by impulse oscillometry, whole
body plethysmography, or rapid thoracic
compression
* Please contact us if you have other procedures you wish to perform (e.g., specific inhalation
challenges).
Note:
The completed application and required documents should be submitted to CPSA together as one
pdf to: pft@cpsa.ab.ca
.
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Pulmonary Function Diagnostics Application for Physician Approval (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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