Diagnostics

EQI Assessor Application Form

Contact Information

Salutation

Mr. Miss Ms. Mrs. Dr.  

First Name

Last Name

Address

   Address

   Address

   City

   Province

Alberta British Columbia Manitoba New Brunswick Nfld and Labrador Nova Scotia NWT Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

   Postal Code

   Phone #

   French Language Proficiency

Yes No

   Email Address

Employer Information

Name

Job title

Department

Employer Address

   Address

   Address

   City

   Province

Alberta British Columbia Manitoba New Brunswick Nfld and Labrador Nova Scotia NWT Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

   Postal Code

   Phone #

Reference (Please note that your reference will be contacted by Accreditation Canada (AC) Diagnostics)

Name

Title

Relationship to you

Email:

Education: (Please list up to 3 of the most relevant educational achievements)

Graduating Year

Degree or Diploma

Institution

Major or Specialization

Graduating Year

Degree or Diploma

Institution

Major or Specialization

Graduating Year

Degree or Diploma

Institution

Major or Specialization

Professional Qualifications: (Please check all that apply)

Technologist or Equivalent

Cardiologist, Internist and Medical Director

Working Knowledge of Diagnostic Imaging Service

Practicing (active) member of applicable regulatory college

Name of College:

Work Experience: (List your 3 most recent employers)

Employer

Position

Years (E.G., 2004-2007)

Please select your area of expertise:

Modality

TTE

Stress Echo 

TEE

Pediatrics

Other

 Supporting Infrastructure

  Management System

  Picture Archiving and Communication System (PACS)

  Information System (RIS)

  Other:

Management/Supervisory Experience:

Please indicate the number of years of management or supervisory experience concurrent clinical work: 0 yrs 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 5+ yrs

Consulting or Teaching

Please indicate if in the past 5 years you have had experience consulting for diagnostic imaging services or teaching students: Yes No

Training and experience with another Accreditation Body

As an assessor, have you completed at least 1 accreditation visit with another accreditation body?   Yes No  

If yes, please state the name of all the accreditation bodies and years of experience as an assessor:

If you have any question please email Accreditation Canada Diagnostics (AC Diagnostics) at eqi@acdiagnostics.ca

Please ensure you email your resume to eqi@acdiagnostics.ca

Please review the form prior to submission.

You must complete this form in one session

Clicking on the “SUBMIT” button will transmit this form to AC Diagnostics.

Please ensure that you see the confirmation screen shortly after you press the submit button. If the confirmation screen is not seen, please email AC Diagnostics at accreditation@acdiagnostics.ca

SUBMIT

The “Submit” button allows you to submit the complete and final form.
IMPORTANT: Modifications cannot be made after Submit.

Version 1.0 (2024-03-07)