Accreditation Assessor Application

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Diagnostics

Assessor Application Form

All fields that are red are required to be completed.

Are you applying to be an assessor for:

Laboratory or Diagnostic Imaging

Note: You must complete this form in one session

Contact Information
Salutation
First Name
Last Name

Address
Address
Address
City
Province
Postal Code
Phone #

Do you speak French with a high enough proficiency to assess in French (this will be verified)	Yes No

Email Address

Emergency Contact
Name
Relationship to you
Phone Number

Employer Information
Name
Job title
Department

Employer Address
Address
Address
City
Province
Postal Code
Phone #

Prefered Mailing Address Home Work

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

Minimum Technologist or Equivalent

PhD., Clinical Chemist, Scientist, Physicist, Medical Director, or Similar

Working Knowledge of Diagnostic Imaging Service

Working Knowledge of a Clinical Medical Laboratory

Practicing (active) member of applicable regulatory college

Name of College:

Work Experience: (Please list up to 3 previous employers)
Employer	Position	Years (E.G., 2004-2007)

Laboratory Professionals

Please select your area of expertise: (please sleect all that apply for the last 3 years)
Anatomic Pathology	Microbiology	Chemistry
Cytogenetics	Cytopathology	Flow Cytometry
Quality Managment	Hematology	Immunology
LIS	Maternal Serum Screening	Molecular Diagnostics
Mycology	Parasitology	Point-Of-Care
Safety	Transfusion Medicine	Virology
Electron Microscopy	Immunohistochemistry	Mass Spectometry
Specimen Collection	Molecular Genetics	HLA
Other

Diagnostic Imaging Professionals

Please select your area of expertise: (please sleect all that apply for the last 3 years)
Modality
Bone Densiometry	MRI - General
	MRI - Breast
CT - General	MRI - Cardiac Interventional Electronic Devices
CT - Cardiac/Angiography
CT - Colonography	Nuclear Medicine

General Radiography - Computed	PET
General Radiography - Digital
General Radiography - Film-Screen	Tele-Mammography
	Tele_Radiography
Interventional
	Ultrasound - General
Mammography - Computed	Ultrasound - Breast
Mammography - Digital	Ultrasound - Echo
Mammography - Film-Screen	Ultrasound - Obstetric
	Ultrasound - Vascular

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 with bench or clinical work:

Consulting or Teaching

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

Training and experience with another Accreditation Body

Have you completed an assessor training course with another accreditation body in the last three years? Yes No

If yes, have you performed at least 1 accreditation visit with another accreditation body in the last three years? Yes No

Committee Member

Have you ever been an Accreditation Canada Diagnostics (Accreditation Advisory Panel, or IQMH) committee member? Yes No

If you have any questions, please email Accreditation Canada Diagnostics at accreditation@acdiagnostics.ca

Please email your resume to accreditation@acdiagnostics.ca

If you don't see a confirmation screen after pressing the submit button, please contact the AC Diagnostics at 416-323-9540.

	The “Submit” button allows you to submit the complete and final form. IMPORTANT: Modifications cannot be made after Submit.
	Version 9.0 (2025-03-06)