Registration of Designated Radiation Equipment - College of Dental Surgeons of Alberta

"*" indicates required fields

Step 1 of 5

Application for Registration of Designated Radiation Equipment

In the province of Alberta, dental x-ray equipment and facilities as well as lasers, are governed by the Occupational Health and Safety Act. This Act specifies that owners of dental x-ray equipment and lasers must arrange the compliance verification/inspection and must ensure the final report is received by the Alberta Dental Association and College along with the completed registration application. Failure to comply with the Act and the Radiation Health and Safety Policy can result in additional fees and/or stop work orders associated with late registration or non-disclosed equipment.

The Alberta Dental Association and College collects this information for the purposes of administration of the Radiation Health and Safety Program under the Alberta Radiation Protection Program. The information collected in this program will not be collected, used or disclosed for any other purpose except as otherwise permitted or required by law. We will retain this information indefinitely.’

Current Facility Name*

Facility Information

Type of Change*

Facility Opened*

mm/dd/yyyy

Effective Date*

mm/dd/yyyy

Previous Facility Name (only Applies if Facility name is changed)

Facility Contact Name*

Prefix First Last

Email*

Facility Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Facility Phone*

Facility Fax

Employer or Employer Designated Responsible Dentist

Do you wish to update the Employer or Employer Designated Responsible Dentist information?*

If not please continue to the next page.

Employer Effective Date*

mm/dd/yyyy

Employer Name*

Employer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Employer Phone*

Employer Fax

Responsible Dentist Information same as Employer above

Information same as Employer above

Employer Designated Responsible Dentist 1 Effective Date*

mm/dd/yyyy

Employer Designated Responsible Dentist 1

Prefix First Last

Employer Designated Responsible Dentist 1 Email*

Employer Designated Responsible Dentist 2 Effective Date

mm/dd/yyyy

Employer Designated Responsible Dentist 2

Prefix First Last

Employer Designated Responsible Dentist 2 Email

Equipment Information

Complete this section of the form for each piece of equipment being registered; including Class 3b and Class 4 lasers.

Do you wish to apply for registration or recertification of your radiation equipment?*

If not please continue to the next page.

Name of Authorized Radiation Protection Inspection Agency that performed Compliance Inspection:*

Date of Inspection*

mm/dd/yyyy

How many Pieces of equipment are you applying for?

If you are applying for more than 10 pieces of equipment please fill out the form again for the remaining pieces.

#1

Employer or Employer Designated Responsible Dentist Name*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#2

Employer or Employer Designated Responsible Dentist Name*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#3

Employer or Employer Designated Responsible Dentist Name*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#4

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#5

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#6

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#7

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#8

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#9

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

#10

Employer or Employer Designated Responsible Dentist*

Prefix First Last

Equipment Status*

Equipment Type*

Location in Facility (Room Name)*

Installation Date*

mm/dd/yyyy

Manufacturer Name*

Model Name*

Application for Registration of Designated Radiation Equipment

Facility Information

Employer or Employer Designated Responsible Dentist

Equipment Information

#1

#2

#3

#4

#5

#6

#7

#8

#9

#10

This application has been verified and submitted by (must be Employer or Employer Designated Responsible Dentist of facility):