Removal of Registered Equipment - College of Dental Surgeons of Alberta

This form is to notify the CDSA Radiation Health and Safety Program of any x-ray equipment, including lasers, that have been decommissioned, sold, made inactive or disposed of.

Facility

Facility Name(Required)

Facility ID

Equipment

How many pieces of equipment are you removing?(Required)

Information for piece #1

Equipment Type(Required)

Location in Facility (Room name)(Required)

Manufacturer Name(Required)

Model Name(Required)

Tube Serial number(Required)

How was this piece of equipment removed?(Required)

Supplier Name(Required)

Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.

Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.

Please describe how equipment was disposed of

Information for piece #2

Equipment Type(Required)

Location in Facility (Room name)(Required)

Manufacturer Name(Required)

Model Name(Required)

Tube Serial number(Required)

How was this piece of equipment removed?(Required)

Supplier Name(Required)

Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.

Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.

Please describe how equipment was disposed of

Information for piece #3

Equipment Type(Required)

Location in Facility (Room name)(Required)

Manufacturer Name(Required)

Model Name(Required)

Tube Serial number(Required)

How was this piece of equipment removed?(Required)

Supplier Name(Required)

Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.

Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.

Please describe how equipment was disposed of

Information for piece #4

Equipment Type(Required)

Location in Facility (Room name)(Required)

Manufacturer Name(Required)

Model Name(Required)

Tube Serial number(Required)

How was this piece of equipment removed?(Required)

Supplier Name(Required)

Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.

Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.

Please describe how equipment was disposed of

Information for piece #5

Equipment Type(Required)

Location in Facility (Room name)(Required)

Manufacturer Name(Required)

Model Name(Required)

Tube Serial number(Required)

How was this piece of equipment removed?(Required)

Supplier Name(Required)

Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.

Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.

Please describe how equipment was disposed of

Confirmation

This application has been verified and submitted by (must be the responsible dentist or employer of the facility):

Employer(Required)

Date Signed(Required)