Facility Information s2
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DIAGNOSTIC ACCREDITATION PROGRAM College of Physicians and Surgeons of British Columbia 300–669 Howe Street Telephone: 604-733-7758 Facility Vancouver BC V6C 0B4 Toll Free: 1-800-461-3008 (in BC) www.dap.org Fax: 604-733-3503
Information Neurodiagnostics - Health Authority
Hospital/Health Centre Name: Health Authority: Neurodiagnostic Service Name: Address: Neurodiagnostic Service Phone No: Projected Date of Facility Opening or Test Starting:
New Test(s) to be Accredited (Check all that apply)
Electroencephalography (EEG) Evoked Potentials (EP) Electromyography (EMG) Nerve Conduction Studies (NCS) Contact Person for Neurodiagnostics Accreditation Activities: Name: Title: Address:
City: Postal Code: Telephone Number: ( ) - Fax Number: ( ) - Email: Cell Number: ( ) -
Neurodiagnostics Service Information
Organizational Chart – please provide the Diagnostic Service organizational chart Leadership Name Title Email Location
Regional Administrative Leader: Regional Medical Leader:
Enhancing public safety through excellence in diagnostic medicine accreditation Facility Information Neurodiagnostics - Health Authority
Health Service Area, Administrative Leader: Health Service Area, Medical Leader: Medical Leader of Neurodiagnostics Service: Administrative Leader of Neurodiagnostics Service: Technical Leader of Neurodiagnostics Service (e.g. Chief Technologist): Other Individuals appointed to leadership positions: (e.g. Professional Practice Leader) Interpreting Physicians First Last CPSBC# Test(s) Location Name Name
EEG EP EMG/NCS On-Site Off-Site Specify Location:
EEG EP EMG/NCS On-Site Off-Site Specify Location:
EEG EP EMG/NCS On-Site Off-Site Specify Location:
EEG EP EMG/NCS On-Site Off-Site Specify Location:
EEG EP EMG/NCS On-Site Off-Site Specify Location:
Is there an interpreting physician present on-site during Yes No testing?
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Are tests transferred to other facilities for interpretation? Yes No If yes, please indicate the name of each interpreting facility, location, test and method of distribution (e.g. Dr. John Doe, ABC Hospital, EEG, CD’s): Name Location Test Method of Distribution
Are tests received from other facilities for Yes No interpretation? If yes, please indicate the location, test and method of distribution (e.g. ABC Hospital, EEG, Courier): Location Test Method of Distribution
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Electroencephalography (EEG)
Test Not Applicable Tests performed: Routine EEG (including awake and asleep recordings) Portable EEG in critical care areas Continuous Video/EEG recordings (SIU-Seizure Investigation Unit) Long-term monitoring in critical care areas Ambulatory recordings Number of technologists (FTE): Technologists are: CAET certified AETC certified CBRET certified ABRET certified Neither, please provide name(s) and qualifications below: Name Qualifications
Is there a dedicated supervisor for this area? Yes No If yes, please provide name(s) and title(s): Dedicated staff or rotate through the area? Dedicated Rotate Days and hours of operation: Are on-call services provided? Yes No Projected number of tests performed daily: Projected number of tests annually: Number of procedure rooms: Are there tests that are only performed by Yes No specialized technical staff?
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Equipment List
Description of Make Model/Serial Year Location (e.g. room equipment Number Manufactured no.)
Who is responsible for the maintenance of diagnostic equipment:
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Evoked Potentials (EP)
Test Not Applicable Tests performed: Adult EP Pediatric EP Visual EP (VEP) Brainstem Auditory EP (BAEP) Somatosensory EP (SSEP) Number of technologists (FTE): Technologists are: CAET certified AETC certified CBRET certified ABRET certified Neither, please provide name(s) and qualifications below: Name Qualifications
Dedicated staff or rotate through the area? Dedicated Rotate Days and hours of operation: Approximate number of tests performed daily: Approximate number of tests performed annually: Number of procedure rooms: Are EPs performed outside of the department? Yes No If yes, please indicate location:
Equipment List
Description of Make Model/Serial Year Location (e.g. room equipment Number Manufactured no.)
Who is responsible for the maintenance of diagnostic equipment:
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Electromyography (EMG)
Test Not Applicable Number of technologists (FTE): Technologists are: CAET certified AETC certified CBRET certified ABRET certified Neither, please provide name(s) and qualifications below: Name Qualifications
Is there a dedicated supervisor for this area? Yes No If yes, please provide name(s) and title(s): Dedicated staff or rotate through the area? Dedicated Rotate Days and hours of operation: Number of procedure rooms: Electromyography (EMG) Tests performed: Adult EMG Pediatric EMG Other: Approximate number of tests performed daily: Approximate number of tests performed annually: Are there dedicated days when tests are Yes No performed? If yes, explain:
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Nerve Conduction Studies (NCS) Studies performed: Adult NCS Pediatric NCS Motor nerve conduction study Sensory nerve conduction study Other: Who performs the NCS? Physician Technologists Approximate number of studies performed daily: Approximate number of studies performed annually: Are NCS performed outside of the department? Yes No If yes, please indicate location:
Equipment List
Description of Make Model/Serial Year Location (e.g. room equipment Number Manufactured no.)
Who is responsible for the maintenance of diagnostic equipment:
Medical Director’s Signature
______Date: ______
Any additional information you wish to add:
Please return form by: Mail: College of Physicians and Surgeons of British Columbia Email: [email protected] Diagnostic Accreditation Program Fax: 604.733.3503 300-669 Howe Street Vancouver BC V6B 0B4
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