Application for Registration of Designated Radiation Equipment X-ray Equipment - College of Physicians & Surgeons of Alberta

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:

Type of diagnostic x-ray 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).

Location of equipment in facility:

Date of expected installation (should be typed in the format mm/dd/yyyy, as in 03/15/2023)

Manufacturer:

Manufacturer date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):

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)*

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.

Name

This field is for validation purposes and should be left unchanged.

Owner information

Facility information

Equipment details

Signature

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