Notification of Change to Equipment Form - Laser - College of Physicians & Surgeons of Alberta

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 CPSA work, which is to protect the public and to guide and regulate Alberta physicians. Please note: Modifications to tubes, generators or anything that alters power of the unit must be tested for compliance by an Authorized Radiation Health Inspection Agency prior to use.

Reason for Notification*

Please select all that apply

Modified Equipment
Relocated Equipment
Decommissioned Equipment

Modified Equipment

Facility name:*

Please fill out the information for the modified equipment:*

Equipment #	Manufacturer	Model	Serial #

Details of modification:*

Relocated Equipment

NEW Facility Name:*

NEW Facility Address:*

Street Address Address Line 2 City Province Postal Code

Location within NEW facility:*

NEW Facility contact name:

First Last

NEW Facility contact email address:*

Enter Email Confirm Email

Current Facility Name:*

Current Facility Address:*

Street Address City Postal Code

Location within current facility:*

Current Facility contact name:

First Last

Current Facility contact email address:*

Enter Email Confirm Email

Please fill out the information for the relocated equipment:*

Equipment #	Manufacturer	Model	Serial #

Decommissioned Equipment

Current Facility name:*

Current Facility address:*

Street Address City Postal Code

Location within current facility:*

Current facility contact name:*

First Last

Current facility contact email:*

Enter Email Confirm Email

Please fill out the information for the decommissioned equipment:*

Equipment #	Manufacturer	Model	Serial #

Reason for decommission:*

Please select one:

Transfered/Sold
Stored
Discarded

Where was the decommissioned equipment transferred or sold to?*

Has the equipment been replaced?*

Yes
No

Signature

Checking this box will act as your signature:*

I certify that, to the best of my knowledge, the information in this form is complete and accurate, and that this equipment and the radiation facility associated with its use, comply with the Occupational Health and Safety Code.

Name of Facility owner:*

Email of Facility owner:*

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.

Comments

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

Notification of Change to Equipment - Laser

Modified Equipment

Relocated Equipment

Decommissioned Equipment

Signature

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