New Facility Application Form - Pulmonary Function

New Facility Application Form - Pulmonary Function

Private or Community / Public Facility
Private Community / Public
Facility Name / Service Name
Facility Address / City / Postal Code
Parent Company Name or Health Authority Name / Corporate Address
Projected date of Facility/Service Opening
Medical Director
Name: / Title:
Address: / City: / Postal:
Telephone Number:
()- / Fax Number:
()- / Email: / Cellular Telephone:
()-
Administrative Director
Name: / Title:
Address: / City: / Postal:
Telephone Number:
()- / Fax Number:
()- / Email: / Cellular Telephone:
()-
Name of Contact Person
Name: / Title:
Address: / City: / Postal:
Telephone Number:
()- / Fax Number:
()- / Email: / Cellular Telephone:
()-
Scope of Pulmonary Function Laboratory Testing
Category IIA
Simple screening spirometry without bronchodilators
Spirometry - before and after bronchodilators
Peak expiratory flow rate / Category IIB
Simple screening spirometry without bronchodilators
Spirometry - before and after bronchodilators
Peak expiratory flow rate
Spirometry - forced expiratory - without bronchodilators
Spirometry - forced expiratory - before and after bronchodilators
Category III
Overnight home oximetry
Simple screening of spirometry without bronchodilators
Spirometry - before and after bronchodilators
Peak expiratory flow rate
Lung volumes
Spirometry - forced expiratory - without bronchodilators
Spirometry - forced expiratory - before and after bronchodilators
Diffusion studies with carbon monoxide / Category IV
IVA Flow volume loops without bronchodilators
IVA Flow volume loops before and after bronchodilators
IVB Progressive exercise test
IVB Ventilation at rest/exercise with blood gases
IVB Exercise in a steady state
IVB Exercise in a steady state - AA gradients
IVC Exercise induced asthma
IVD Inhalation challenge
IVE CO2/O2 responsive of respiratory centres
IVF Plethysomography
IVH Preciptin tests
IVI Oximetry at rest, with or without oxygen
IVI Oximetry at rest and exercise, with or without oxygen
IVK Inspiratory and expiratory muscle strength
Are pediatric studies performed? / Yes No
If adding a new category(s) to be accredited, please specify below: N /A
IIA
please specify with test(s) / IIB
please specify with test(s) / III
please specify with test(s) / IV A-K
please specify with test(s)
Other Pulmonary Function categories already accredited in Facility/Department:
Interpreting Physicians
First Name / Last Name / CPSBC # / Category Interpreting / Location of Physician
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
Have all physicians been credentialed by the College of Physicians and Surgeons of BC? / Yes No
Is there an interpreting physician present on-site during testing? / Yes No
To which address should mail be sent? Facility Other:
Medical Directors Signature
______Date: ______

Please mail, fax or scan/email form to:

Email:

Fax: 604 – 733 – 3503

Attn: Jacqueline, DAP

Mailing address:Jacqueline Murtough, Accreditation Specialist

College of Physicians and Surgeons of British Columbia

Diagnostic Accreditation Program

300-669 Howe Street

Vancouver BC V6H 0B4

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Form revised: August 2016