Registration of Designated Radiation Equipment - College of Dental Surgeons of Alberta

"*" indicates required fields

Step 1 of 5

Application for Registration of Designated Radiation Equipment

In the province of Alberta, dental x-ray equipment and facilities as well as lasers, are governed by the Occupational Health and Safety Act. This Act specifies that owners of dental x-ray equipment and lasers must arrange the compliance verification/inspection and must ensure the final report is received by the College of Dental Surgeons of Alberta along with the completed registration application. Failure to comply with the Act and the Radiation Health and Safety Policy can result in additional fees and/or stop work orders associated with late registration or non-disclosed equipment.

The College of Dental Surgeons of Alberta collects this information for the purposes of administration of the Radiation Health and Safety Program under the Alberta Radiation Protection Program. The information collected in this program will not be collected, used or disclosed for any other purpose except as otherwise permitted or required by law. We will retain this information indefinitely.’

Facility Information

Current Facility Name*

Type of Change*

Facility Opened*

mm/dd/yyyy

Effective Date*

mm/dd/yyyy

Previous Facility Name (only Applies if Facility name is changed)

Facility Contact Name*

Prefix First Last

Email*

Facility Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Facility Phone*

Facility Fax

Responsible Dentist and Employer

Do you wish to update the Responsible Dentist and Employer Information?*

If not please continue to the next page.

Employer Effective Date*

mm/dd/yyyy

Employer Name*

Email*

Responsible Dentist 1 Effective Date*

mm/dd/yyyy

Responsible Dentist 1*

Prefix First Last

Responsible Dentist 1 Email*

Responsible Dentist 2 Effective Date

mm/dd/yyyy

Responsible Dentist 2

Prefix First Last

Responsible Dentist 2 Email

Responsible Dentist 3 Effective Date

mm/dd/yyyy

Responsible Dentist 3

Prefix First Last

Responsible Dentist 3 Email

Equipment Information

Complete this section of the form for each piece of equipment being registered; including Class 3b and Class 4 lasers.

Do you wish to register new equipment or recertify existing radiation equipment?*

Name of Authorized Radiation Protection Inspection Agency that performed Compliance Inspection:*

Date of Inspection*

mm/dd/yyyy

How many Pieces of equipment are you applying for?

If you are applying for more than 10 pieces of equipment please fill out the form again for the remaining pieces.

#1

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#2

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#3

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#4

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#5

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#6

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#7

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#8

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#9

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

#10

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Tube Serial Number*

Application for Registration of Designated Radiation Equipment

Facility Information

Responsible Dentist and Employer

Equipment Information

#1

#2

#3

#4

#5

#6

#7

#8

#9

#10

This application has been verified and submitted by (must be Employer or Employer Designated Responsible Dentist of facility):