Diagnostics

ICHSC Assessor Application Form

 

 

 

Contact Information

Salutation

 

First Name

Last Name

 

 

Address

 

   Address

   Address

   City

   Province

   Postal Code

   Phone #

   French Language Proficiency

   Email Address

 

Employer Information

Name

Job title

Department

 

 

Employer Address

 

   Address

   Address

   City

   Province

   Postal Code

   Phone #

 

Prefered Mailing Address    

 

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)

Name of College:

 

Work Experience: (List your 3 most recent employers)

Employer

Position

Years (E.G., 2004-2007)

 

 

 

 

 

 

 

 

Area of expertise

 

Please select your area of expertise:

Modality

 

 

 

 

 

 

 

 

 

 

 

 

 

Supporting Infrastructure

:

  

 

Management/Supervisory Experience:

Please indicate the number of years of management or supervisory experience concurrent clinical work:

 

Consulting or Teaching

Please indicate if in the past 5 years you have had experience consulting for diagnostic imaging services or teaching students:

 

Training and experience with another Accreditation Body

As an assessor, have you completed at least 1 accreditation visit with another accreditation body?    

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

 

 

If you have any questions please email Accreditation Canada Diagnostics (AC Diagnostics) at ICHSC@accreditation.ca

Please ensure you email your resume to ICHSC@accreditation.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 us at at ICHSC@accreditation.ca

 

 

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

 

Version 1.1 (2024-04-05)