Designated Radiation Equipment - Registration Application Form
Instructions
1. Complete and sign the attached application form
Use TAB key to proceed
2. Send the completed application form to the Department of Environment, Health & Safety.
3. If your facility is in Edmonton arrange with the Radiation Safety Office (492-5655) to perform compliance
verification of the equipment and facility. There is no charge for this service.
4. If your facility is not in Edmonton you must contact one of the other Authorized Radiation Protection
Agencies listed below for compliance verification. There is a charge for their services.
5. You will receive a compliance verification report from the agency performing the inspection of your equipment.
6. If there is any item(s) of non compliance identified it must be corrected.
7. Written verification of corrective action must be provided to the Department of Environment, Health & Safety
before your equipment will be registered for use.
8. If you have any question on how to complete the application form or a question concerning the inspection /
registration process contact the Radiation Safety Office at 492-5655.
Note: Applications must be submitted at least 30 days prior to the date of anticipated equipment operation.
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Part 1 General Information
A.
Reason For Application
Equipment:
new
renewal
modification
relocation
Facility:
new
renewal
modification
B. Owner Information
Name:
Phone:
Fax:
Address:
E-mail:
C. Type of Facility
research
education
dental
medical
veterinary
other – specify below
Specify:
Last revised February, 2013
Page 1
D. Type of Designated Equipment
X-ray:
radiographic
fluoroscopic
dental panoramic
dental pan/ceph
dental intraoral
cabinet
diffraction
accelerator(<10 MeV)
other – specify below
Laser:
Class 3b
Class 4
Specify:
E. Designated Equipment Description
Installation:
stationary
mobile
portable
Manufacturer:
Model:
Date:
Location:
Serial No.:
Tag No.:
F. Details of Proposed Use:
Part 2 Equipment Specifications
A. Lasers
gas
continuous wave
beam diameter (at 1/e2 pts)
beam divergence:
wavelength:
focal length (lens):
numerical aperture (fibre)
pulsed
solid state
Laser eyewear: wavelength:
cm
mrad
nm
cm
other (specify)
Nm optical density
output power:
power density:
pulse energy:
single pulse duration:
pulse repetition
B. X-ray Equipment
mA per irradiation:
kVp per irradiation:
Time per irradiation (sec)
Irradiations/week:
2
watts
watts/cm2
joules
usec
hertz
Part 3 Personnel
Surname
Given Name
m/f
Job Title
Year
Equipment Safety
Training
Place
The information on this form is being collected under the authority of Section 33c of the Alberta Freedom of Information and Protection of Privacy Act for
the purpose of administering the radiation protection program through the Department of Environment, Health & Safety. Questions concerning the
collection, use or disposal of this information should be directed to: Department of Environment, Health & Safety, 3-107, Research Transition Facility,
University of Alberta, telephone 780-492-5655, fax 780-492-7790.
Part 4 Signatures
Applicant Signature
DATE
Department Head Signature
DATE
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