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Application for Registration of Designated Radiation Equipment X-ray Equipment
Owner information
Is this equipment owned by a Zone?
Yes
No
Which zone?
Owner name:
First
Last
Contact name:
First
Last
Address:
Street Address
City
Postal Code
Phone:
Fax:
Email:
Has imaging modality accreditation been granted for the type of equipment being registered?
Yes
No
(If no, visit the Diagnostic Imaging Accreditation web page for more information)
Facility information
Facility name:
Contact name:
First
Last
Facility address:
Street Address
City
Postal Code
Phone:
Fax:
Email:
Equipment details
Please indicate area of practice where the equipment is located:
Cardiology
Dental
Dermatology
Obs/Gynecology
Oncology
Ophthalmology
Physiotherapy
Podiatry
Radiology
Research
Surgery
Type of diagnostic x-ray equipment:
General X-ray
Bone Densitometry
Cabinet x-ray equipment
Computerized Tomography
Diffraction & Analysis x-ray equipment Particle accelerator
Fluoroscopy - General
Fluoroscopy – Special
Fluoroscopy – Cardiac CatherizationProcedures/Angiography/Interventional
Mammography - Analogue
Mammography - Digital
Mobile Fluoroscopy (C-Arm)
Mobile Radiography
Therapeutic x-ray equipment
Therapy simulator equipment
Is the above equipment:
Stationary
Mobile
Portable
Temporary
Temporary until when? (Dates should be typed in the format mm/dd/yyyy, as in 03/15/2023).
MM slash DD slash YYYY
Location of equipment in facility:
Date of expected installation (should be typed in the format mm/dd/yyyy, as in 03/15/2023)
MM slash DD slash YYYY
Manufacturer:
Manufacturer date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):
MM slash DD slash YYYY
Model #:
Serial #:
Does the generator supply more than one tube?
Yes
No
Please list the tube serial #s:
*Click the + to add an additional serial number
If equipment is from another facility, please indicate facility name:
Signature
Checking this box will act as your signature:
*
I confirm the information in this application is complete and accurate, and that the structural shielding and equipment shielding meet requirements. I also confirm the equipment and facility comply with the Occupational Health and Safety Code.
Name of Facility owner:
*
Email
*
This is the email address we will send a submission confirmation notification to.
Enter Email
Confirm Email
Date (should be typed in the format mm/dd/yyyy, as in 03/15/2023)
*
MM slash DD slash YYYY
Your privacy is important to us!
We collect, use and/or disclose your personal information with your consent unless otherwise authorized or required by legislation. As per our CPSA Privacy Statement, we collect and use your personal information to do our CPSA work, which is to protect Albertans and to guide and regulate Alberta physicians.
Phone
This field is for validation purposes and should be left unchanged.
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CPSA's 2023 annual report now available
Find out about our year through stats and stories.