Use this form to notify the CDSA of any x-ray equipment, including lasers, that have been decommissioned, sold, made inactive or disposed of. Guidelines in section B.6.0 of the Health Canada Safety Code 30 Radiation Protection in Dentistry should be followed. Safety Code 30 – Radiation Protection in DentistryFacilityName of Facility Owner(Required) Dr. Prefix First Last Owner Email(Required) Facility Name(Required) Facility IDFacility Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country EquipmentHow many pieces of equipment are you removing?(Required)12345Information for piece #1 Equipment Type(Required)(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room name)(Required) Manufacturer Name(Required) Model Name(Required) How was this piece of equipment removed?(Required)(Please Select One)Decommissioned by SupplierSoldEquipment still in office but not in useOwner DisposalSupplier Name(Required) Name of Person Sold to Dr. Prefix First Last Name of Business Sold to Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.Please describe how equipment was disposed of Information for piece #2 Equipment Type(Required)(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room name)(Required) Manufacturer Name(Required) Model Name(Required) How was this piece of equipment removed?(Required)(Please Select One)Decommissioned by SupplierSoldEquipment still in office but not in useOwner DisposalSupplier Name(Required) Name of Person Sold to Dr. Prefix First Last Name of Business Sold to Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.Please describe how equipment was disposed of Information for piece #3 Equipment Type(Required)(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room name)(Required) Manufacturer Name(Required) Model Name(Required) How was this piece of equipment removed?(Required)(Please Select One)Decommissioned by SupplierSoldEquipment still in office but not in useOwner DisposalSupplier Name(Required) Name of Person Sold to Dr. Prefix First Last Name of Business Sold to Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.Please describe how equipment was disposed of Information for piece #4 Equipment Type(Required)(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room name)(Required) Manufacturer Name(Required) Model Name(Required) How was this piece of equipment removed?(Required)(Please Select One)Decommissioned by SupplierSoldEquipment still in office but not in useOwner DisposalSupplier Name(Required) Name of Person Sold to Dr. Prefix First Last Name of Business Sold to Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.Please describe how equipment was disposed of Information for piece #5 Equipment Type(Required)(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room name)(Required) Manufacturer Name(Required) Model Name(Required) How was this piece of equipment removed?(Required)(Please Select One)Decommissioned by SupplierSoldEquipment still in office but not in useOwner DisposalSupplier Name(Required) Name of Person Sold to Dr. Prefix First Last Name of Business Sold to Note: It is strongly recommended that disposal of X-ray equipment be delegated to an X-ray service provider that specializes in the disposal of such systems. Safe work practices during disposal must be used so that workers are not exposed to hazards.Note: Equipment must be unplugged and labeled DO NOT USE UNTIL THIS HAS BEEN INSPECTED AND RE-REGISTERED so that it may not accidentally put back into service.Please describe how equipment was disposed of ConfirmationThis application has been verified and submitted by (must be owner of facility):Name(Required) Dr. Prefix First Last Date Signed(Required) YYYY slash MM slash DD Consent(Required) I certify that the above information is complete and accurate.The removal of the above equipment complies with all aspects of the Occupational Health and Safety Act and the Radiation Health and Safety Program. (The owner must certify). Δ