Name of applicant for CCPM “Membership”: Click here to enter text.

Number of years you have known the applicant: Click here to enter text.

Name and organization of Referee: Click here to enter text.

Referee certification, or number of years of experience as medical physicist within the organization: Click here to enter text.

Size of comparison group: Click here to enter text.

Please provide your assessment of the applicant in the following areas:

Professional attitudes and communication skills:

Unsatisfactory	Adequate	Good	Very Good	Outstanding
Interpersonal Skills	☐	☐	☐	☐	☐
Initiative	☐	☐	☐	☐	☐
Sense of responsibility	☐	☐	☐	☐	☐
Adaptability	☐	☐	☐	☐	☐
Oral and written skills	☐	☐	☐	☐	☐

Medical physics experience in the nuclear medicine sub-specialty that you have direct ability to assess: (The Credentials Committee does not expect Membership applicants to have significant experience in all areas.)

Unable to assess	Little or no knowledge or experience	Knowledgeable but has limited experience	Could carry out task with minimal supervision	Very competent: able to work independently
Able to independently perform NEMA testing of a gamma camera, analyze the data and interpret the results provided.	☐	☐	☐	☐	☐
Able to perform quality control tests as appropriate to a radionuclide dose calibrator and interpret the results provided	☐	☐	☐	☐	☐
Able to discuss factors relevant to image quality with respect to optimization of administered doses of clinical studies.	☐	☐	☐	☐	☐
Provide radiation protection advice	☐	☐	☐	☐	☐
Knowledge of equipment selection and evaluation	☐	☐	☐	☐	☐
Design a quality assurance program for a new equipment within the clinic	☐	☐	☐	☐	☐
Talk to staff, public or media about sensitive professional issues	☐	☐	☐	☐	☐

An assessment of the candidate’s clinical experience is particularly important. Please evaluate the candidate’s application as follows:
I agree with the working experience which is claimed in Sections 2.4, 3(A) AND 3(B):
Yes	☐	No	☐	Unable to assess ☐

I believe that the working experience claimed is relevant according to the criteria set forth in Section D.2 of the Regulations of the CCPM:

Yes	☐	No	☐	Unable to assess ☐

In making the above assessment, the following guidance should be taken into account:

Time spent in pursuit of a graduate degree is not considered to be relevant experience;

The experience should be comprehensive within the specialty;

Residency training within a recognized centre is considered relevant experience;

A research associate position would not generally provide comprehensive and hence relevant experience. Where appropriate, patient related experience could include work with normal volunteers.

Evaluation of the candidate

In the space provided or on a separate signed sheet with your organization's letterhead, please comment on the following items with respect to the applicant:

Your confidence in clinical decisions made by the candidate;

General comments on the strengths and weaknesses of the applicant as a competent clinical medical physicist;

His/Her suitability for College Membership;

Review their application and comment on the information provided.

Click here to enter text.

I recommend the applicant for Membership in the CCPM (check one)

Yes	☐	No	☐	Unable to Assess ☐

Date: Click here to enter a date.	Referee’s signature:

Send this form to:

CCPM Registrar
300 March Road, Suite 202

Kanata, ON K2K 2E2 Canada

Or:

Fax: 613-595-1155

Email: gisele.kite@ccpm.ca