Confirmation of Mammography Room Shielding - College of Physicians & Surgeons of Alberta

Reason for confirmation of room shielding:

New Registration
Relocation
Room/Equipment Modification
Recertification

Facility name:

Room name:

Manufacturer:

Equipment #:

Model:

Serial #:

Please check to confirm the following:

The physical room where the equipment is located was reviewed and has adequate room shielding in place.
For CAR-MAP equipment - This review was performed, documented and signed off by a Medical Physicist.
For Non-CAR equipment - This review was performed, documented and signed off by an Authorized Radiation Health Inspection Agency.
The room shielding information is part of the Compliance Verification Report submitted to CPSA by the Medical Physicist.

Signature

Checking this box will act as your signature:*

As the owner of this imaging Mammography equipment, I confirm the information in this form is complete and accurate.

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.

Signature

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