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Notification of Change to Equipment - Laser
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
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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)
*
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.
Comments
This field is for validation purposes and should be left unchanged.
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