C ONJOINT A CCREDITATION S ERVICES I NTERNATIONAL
Revised by CMA Accreditation January 2014
Complete and send this application form with preliminary assessment fee of $2620.00 for 2014 to:
CMA Conjoint Accreditation Services c/o 8872147 Canada Inc.
,
a CMA subsidiary
1867 Alta Vista Drive, Ottawa ON K1G 5W8 by fax to 613 565-7704
or by email to accreditation@cma.ca
Name of program:
Designated health science profession: Choose an item.
Educational level:
 Certificate
 Diploma
 Baccalaureate degree
 Masters’ degree
 Other: Please specify
Corporate authority* for the educational program:
 Single corporate authority (i.e., one institution; must be in Canada)
Name of the institution (i.e., contact site*):
Address:
Website:
Twitter (if applicable): or
 Joint corporate authority (i.e., more than one institution; contact site* must be in Canada)
(Appendix A must be completed)
Name of institution in Canada (i.e., contact site*):
Address:
Website:
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Twitter (if applicable):
*See definition of key terms at www.cma.ca/accredit
Name(s) of other institution(s):
Address:
Website:
Twitter (if applicable):
Program’s primary contact person* (at contact site* in Canada):
Name**: Title
:
Telephone: Fax:
Email:
Program’s secondary contact person* (at international delivery site):
Name**: Title
:
Telephone:
Email:
Telephone:
Email:
Fax:
Dean/VP Academic*** or equivalent of the program (if different from the contact person listed above).
Name: Title:
Fax:
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Applicable to programs that are re-applying for accreditation following an unsuccessful assessment:
Date of previous submission:
Date of previous assessment:
Previous assessment: Phase I  Phase II 
Attach a program report listing the actions taken and planned (with timelines) in response to the previous assessment (“action report”).
Any program that re-registers as a result of an unsuccessful phase I or after receiving a status of accreditation withheld must arrange for a program-specific CMA accreditation workshop with program staff.
*See definition of key terms at www.cma.ca/accredit
**These individuals will receive a copy of all communications regarding the program.
***This or these individual(s) will receive formal communications regarding accreditation policies and the program’s accreditation status.
If approval to deliver this program is required from a governmental or other authority in the jurisdiction outside Canada, specify the authority and date(s) of approval, and attach a copy of the approval
document(s).
Name of authority Date of approval
Name of authority Date of approval
Program type:
 New program (no graduates)
 Program with graduates
 Program offered since:
Program delivery (check all that apply):
 Full-time
 Part-time
 Traditional classroom delivery
 Distance/online education
 Mixed, hybrid or blended model (Traditional classroom and distance/online education delivery).
Please provide details:
 Program delivered at a single campus or location
 Program delivered at more than one campus or location (currently or in the near future). Please provide details and attach a list of locations with full address and contact person at each location:
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 Program with single lab facilities
 Program with lab facilities in different locations/city
Program details:
Program duration in months:
Number of cohorts per year:
Cohort start month or months:
Approximate number of students in each cohort:
Program structure: Attach a detailed program map/plan showing the sequence of all courses and clinical/practicum placements.
Please complete the following grid if the information is not already included in attached map/plan:
Semester/Term Duration (in weeks) Approximate start
(e.g. mid-May, early
January
Didactic (D) or
Practicum (P)
Clinical or practicum site(s): List the official name, name of corporate/legal authority if applicable and address of all hospitals, clinics and emergency medical services that provide student placement.
Name of placement site
Address (street name and city) Name of legal corporate authority if different from name of placement site
Current and imminent student cohorts: Complete the following grid.
Program start date
(year/month)
Program end date
(year/month)
Number of students per cohort
Length (in weeks) of didactic and clinical/ preceptorship portions of the program
Program delivery format
(full-time, parttime, distance, etc.)
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I have secured the most recent edition of the national competency profile* (Canada) for the profession for which accreditation is requested?
Name: Signature:
Optimal target date for the first accreditation visit of your program:
Orientation to the accreditation process: Are you interested in the following orientation options?
(Available on a cost recovery basis)
Accreditation workshop (workshop fees applies)
Participation of a program personnel member as an observer on a survey
 Yes
 Yes  No
 No
(Capacity permitting)
*See definition of key terms at www.cma.ca/accredit
Payment (payable to 8872147 Canada Inc., a subsidiary of the Canadian Medical Association) by:
 Cheque  Visa  MasterCard  American Express
Credit card number:
Name of cardholder:
Expiry date:
Signature:
GST/HST 83803 3785 RT0001
QST/TVQ 1222116704
Do not send credit card information by email.
Statement of intent
Submission of the completed application for accreditation form (international) with the required evidence of program eligibility for registration (Appendix B) constitutes a statement of intent to apply for accreditation in accordance with the Canadian Medical Association policies of Conjoint Accreditation
Services International, Requirements for accreditation and Program assessment procedures.
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Administrator(s)*** representing the program’s corporate authority:
Contact Site (in Canada) Other institution (if applicable)
Name
Title
Name
Title
Email
Signature
Email
Signature
Date Date
***This or these individual(s) will receive formal communications regarding accreditation policies and the program’s accreditation status.
The registered trademarks of the Canadian Medical Association are used under license.
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(to be completed only by programs with joint corporate authority*)
List of key
accountabilities
Name of institution Name of institution Name of institution
Makes strategic decisions about the program
Makes financial decisions about the program
Owns the intellectual property of the program
(curriculum, courses, etc.)
Executes agreements with partner sites
Employs program personnel
Accepts students into the program
Provides liability insurance for students
Provides learning resources for the program
Approves program policies
Grants academic recognition, e.g. certificate/diploma/degree
Conducts total program evaluation
*See definition of key terms at www.cma.ca/accredit
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1.0 The program must be under the governance of a corporate authority that includes a Canadian educational institute that has a CMA accredited program in
Canada in that health science profession.
To be submitted by all programs with the completed application form.
Condition of eligibility Information to be submitted Evidence submitted by program
(please number any supporting documents)
1.1 Corporate authority for the educational program delivered outside Canada, and its relationship to the corporate authority for the program delivered in
Canada.
1.2 Organizational chart(s) of the educational institution and program outside Canada.
1.3 Description of the decisionmaking process for the health science program delivered outside Canada and relationship with the decision-making process for the program delivered by the institute in Canada.
1.4 Description of the educational institute’s responsibility for didactic and clinical education in the program delivered outside
Canada.
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2.0
Condition of eligibility Information to be submitted
The program must be structured so that all educational elements
(didactic and clinical) are documented and delivered in their entirety in English or
French at or above the language proficiency level required for entry to the institution’s health science professional program in Canada.
2.1 Overview of the
English/French language requirements of the secondary school system in the country where the program is being delivered.
2.2 Information on the educational institute’s
English/French language benchmarks for the health science program delivered outside Canada and comparison with the language benchmarks for the program delivered in
Canada.
2.3 Information on the educational institute’s
English/French language assessment process for the health science program delivered outside Canada and comparison with the language assessment process for the program delivered in Canada.
2.4 Overview of the
English/French language support systems for students in the program outside Canada.
Evidence submitted by program
(please number any supporting documents)
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Condition of eligibility Information to be submitted
3.0 The program must have access to clinical facilities and clinical practices that enable students to attain all competencies specified in the Canadian competency profile for the health science profession.
Competencies related to legal and ethical protocols can be met within local or regional health system frameworks and jurisprudence, provided that these systems comply with international norms of personal safety and human rights.
3.1 Information on clinical facilities and technical equipment available for students in the program delivered outside Canada.
3.2 Data on clinical workloads
(volume and variety) of the departments that provide clinical placements for students.
3.3 Information on any variances in clinical practice at the sites outside Canada compared to clinical practices at sites in Canada, e.g., WHMIS, biohazards protocol, etc.
3.4 List of any program/curriculum changes or adaptations in the program delivered outside Canada compared to the program delivered by the institute in Canada.
Evidence submitted by program
(please number any supporting documents)
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