CCPM Certification - Applicant Assessment Form

Application (Optional)

YesNo

Physician?

Number of years you have known the applicant (Required)

Name and organization of Referee (Required)

Size of comparison group (Required)

Professional attitudes and communication skills

Please provide your assessment of the applicant in the following areas

Interpersonal Skills (Required)

Initiative (Required)

Sense of responsibility (Required)

Adaptability (Required)

Oral and written skills (Required)

Medical physics experience that you have direct ability to assess

An assessment of the candidate’s clinical experience is particularly important. 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.

(The Credentials Committee does not expect Membership applicants to have significant experience in all areas)

Knowledge of equipment selection and evaluation (Optional)

Design a quality assurance program for a new equipment within the clinic (Optional)

Talk to staff, public or media about sensitive professional issues (Optional)

I agree with the working experience which is claimed in Sections 2.4, 3(A) AND 3(B) (Optional)

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. (Optional)

Comments (Required)

I recommend the applicant for Membership in the CCPM (Required)

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CCPM Certification - Applicant Assessment Form