Fillable Vestibular Testing Application for Approval to Direct Vestibular (College of Physicians & Surgeons of Alberta)

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Vestibular Testing Application for Approval to Direct Vestibular (College of Physicians & Surgeons of Alberta)

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The Vestibular Testing Application for Approval to Direct Vestibular (College of Physicians & Surgeons of Alberta) form is 3 pages long and contains:

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  • 17 check-boxes
  • 58 other fields

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File type: PDF

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Vestibular Testing
Application for Approval to Direct
Vestibular Disorder Laboratory
1
Application to Direct – Vestibular 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. Specialty: Neurology Otolaryngology
2. I
have completed the minimum equivalent of one year extra training in neurotology:
Yes No
3. M
y training 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.
(Note: This evidence of training and competence is required.) Yes No
Vestibular Testing
Application for Approval to Direct
Vestibular Disorder Laboratory
2 A
pplication to Direct – Vestibular Testing
5. My experience is as follows:
Institution
Dates
From (Month/Year)
To (Month/Year)
6.
Type/Description of Procedure
Check only
those
procedures
for which you
are
requesting
approval.
Total number of
procedures
performed in the
past year.
Numbers must
be provided for
requests to be
processed.
A. Basic ENG
• EOG calibration
• Saccade test
• Spontaneous and gaze evoked nystagmus
• Ocular pursuit testing
• Positional nystagmus
• Bithermal caloric test
• Failure of fixation suppression
B. Specialized Procedures
• Rotation testing (rotating chair)
• Posturography
• Optokinetic nystagmus (OKN)
• Others
Vestibular Testing
Application for Approval to Direct
Vestibular Disorder Laboratory
3 Appl
ication to Direct – Vestibular Testing
7. Expected Practice Start Date: ________________________________________
Pri
vacy 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.
Appli
cant 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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Vestibular Testing Application for Approval to Direct Vestibular (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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