On-line Application Form Accreditation Nuclear Medicine Departments Title *Prof.Dr.Mrs.Ms.Mr.Other First Name * Middle Name Family Name * Department * Institute * Street * Post Code * City * Country *AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe Phone * Fax * E-Mail * If the aforementioned Department gain the Accreditation (tick appropriate box)I authorize UEMS/EANM to publish on the website the name and the data of the Centre.I do not authorize UEMS/EANM to publish on the website the name and the data of the Centre. Are you applying for accreditation in the whole field of Nuclear Medicine including PET and therapy or are you applying for accreditation in limited areas, if so which areas? (Certificate should specify those areas!!!)YesNo Please specify those areas: Are physics services (i.e. Medical Physicist) provided according to local regulation? *YesNo Please indicate of the total number of examinations procedures performed in the last year and detailed protocols of the five most frequently performed in vivo procedures examinations. The Committee will evaluate the application file and select at random five further procedures which are offered by the facility and request the detailed protocols for these examinations procedures in addition to the five most commonly performed. * A copy of the ISO certificate. Uploadfile 1: * The list of in vivo investigations performed in the department, in frequency descending order. Uploadfile 2: * The protocols or operational instruction sheets of the 5 most frequent investigations Uploadfile 3: * The name of at least one certified nuclear physician working full-time in the department and a copy of his/her Nuclear Medicine certification or degree (in case of part-time physicians only, a list of physicians whose cumulated workload is at least full-time equivalent is needed). Uploadfile 4: * Any other document the applicant would think useful. CANMD will then analyse these documents and randomly choose 5 other investigations from the list sent by the applicant. The applicant will then be asked to send us the corresponding 5 protocols or operational instruction sheets. For each of these 10 protocols a short comment mentioning the main source(s) from which the protocol is derived (eg SNM guidelines, national guidelines, books, articles, etc.) is required. Uploadfile 5: * REGISTRATION AND PAYMENT (tick appropriate box) *At the time of the request of accreditation, the Department should pay € 250.00.If the Department passes the examination, it must complete the payment (€ 250.00).The invoice will be sent by the UEMS/EBNM Secretariat after receiving the online application. *Registration fee (total amount):........................................... 500.00 € Please transfer the fee to: Bank transfer to UEMS/EBNM bank account: (all charges for the ordering customer)Bank: BNP Paribas FortisBeneficiary: AISBL UEMS/S.NUCLEAR MEDICINEIBAN: BE26 0016 8460 1929 EURBIC: GEBABEBBstating your name and “Accreditation Department” – Centre name – City. Please make any transfer free of charge for the beneficiary. SendThe form has been submitted Successfully!Another SubmissionThere was an error trying to send your message. Please try again later.There was an error trying to send your message. Please try again later.