Application for
Diagnostic (DIAG) Track Instructor

There are three requirements for DIAG Track Instructor (TI):
1. Certification as DIAG Independant Practitioner (IP).
2. A point for each Question #6,7,8.
3. A reference from a Master Instructor in Question #9.

Applications are processed within 30 days.
Asterisk denotes required answer.

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* 1. Please choose one of the following options for your DIAG TI application:

I am applying for temporary DIAG Track Instructor (TI) status. This is for DIAG IP members that have not taught at previous DIAG IP certification courses and require temporary TI status to apprentice as a TI at an upcoming course. Temporary TI status is valid for 10 days.

I am applying for permanent DIAG Track Instructor status. This is for DIAG IP members that have taught at previous DIAG IP certification courses.

I am applying for temporary modular DIAG TI status. This is for modular DIAG IP members (i.e. members that are IP certified for specific modules within the DIAG track) that have not taught at previous DIAG IP certification courses and require temporary TI status to apprentice as a TI at an upcoming course. Temporary TI status is valid for 10 days.

I am applying for permanent modular DIAG TI status. This is for modular DIAG IP members (i.e. members that are IP certified for specific modules within the DIAG track) that have taught at previous DIAG IP certification courses.

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* 2. Please enter the date.

Select the date below:

Date

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* 3. Please enter your name.

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* 4. Please identify your profession:

Nursing professional

Paramedical

Resident

Physician Assistant

Medical student

Other (please specify)

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* 5. Please enter your IP number.

You must answer affirmative for each Question #6,7,8 in order to be certified as a DIAG TI and proceed to the next question.

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* 6. Please confirm that:
(1 point)

I have at least two years of DIAG scanning experience

Please state number of years

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* 7. Have you taught at a CPoCUS-accredited DIAG course? Or taught at other non-CPoCUS- accredited courses? Please include course name and date.(1 point)

Yes

Please list course name(s) and dates or individuals

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* 8. Have you completed instructor training at a CPoCUS-accredited DIAG course or instructed in a supervised setting ? Please include course name, date, and supervisor.
(1 point)

Yes

Please list course name(s) and dates or supervisor names

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* 9. Please provide a short reference from an DIAG Master Instructor. (1 point)

I have provided an online reference by sending the following link to the Master Instructor:
https://www.surveymonkey.com/r/MIref

I have provided a hardcopy of a reference letter in Question #10

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* 10. Attach additional material (if applicable).

Please label your file with your full name

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 11. Attach additional material (if applicable).

Please label your file with your full name

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 12. Attestation by applicant:

I pledge to uphold CPoCUS values including rigorous standards of POCUS training and non-distribution of certification exams prior to examination.

Application for Diagnostic (DIAG) Track Instructor

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* 1. Please choose one of the following options for your DIAG TI application:

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* 2. Please enter the date.

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* 3. Please enter your name.

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* 4. Please identify your profession:

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* 5. Please enter your IP number.

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* 6. Please confirm that:(1 point)

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* 7. Have you taught at a CPoCUS-accredited DIAG course? Or taught at other non-CPoCUS- accredited courses? Please include course name and date.(1 point)

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* 8. Have you completed instructor training at a CPoCUS-accredited DIAG course or instructed in a supervised setting ? Please include course name, date, and supervisor.(1 point)

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* 9. Please provide a short reference from an DIAG Master Instructor. (1 point)

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* 10. Attach additional material (if applicable).

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* 11. Attach additional material (if applicable).

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* 12. Attestation by applicant:

Application for
Diagnostic (DIAG) Track Instructor

* 6. Please confirm that:
(1 point)

* 8. Have you completed instructor training at a CPoCUS-accredited DIAG course or instructed in a supervised setting ? Please include course name, date, and supervisor.
(1 point)