Notification of ownership of radiation equipment

This information is being collected for the purposes of administering and enforcing the Workers’ Safety and Compensation Act and is collected under the authority of that Act and the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443.

Owner of the Equipment

First Name

Last Name

Business Name

Street Number

Street Name

City

Province/Territory

Postal Code

Country

Primary phone number

Nature of the owners business

Hospital Education and Training Dental Other medical Industrial and Commercial Veterinarian Research and Development

Radiation Equipment Location

Street Number

Physical location of the equipment

Street Name

City

Postal Code

Primary phone number

Provide information about all radiation equipment which is kept at the same location.
Make	Model/Serial No.	Date installed at this location	Function*

*Function options include: Therapy, Radiography, Conventional Fluoroscopy, Remote Control Fluoroscopy, Mammography, Mobile Dermatology, Training/Instruction, Demonstration, repair, installation, Industrial progress control, Analytical (Diffraction) Testing, Other.

The owner of this radiation equipment owns the other radiation equipment at other locations

Yes No

The number of workers using the radiation equipment

Owner of Premises where the radiation equipment is located

First Name

Last Name

Business Name

Same address as the location of equipment

Yes No

Primary phone number

Person Responsible for safe use of equipment

First Name

Last Name

Business Name

Same address as the location of equipment

Yes No

Primary phone number

Signature, consent, declaration

Owner Agent for the owner

hereby notify the board of ownership of radiation equipment as required under section 3 of the Radiation Protection Regulations.

Separate notification is required in respect of each location.

By checking this box I declare that the information provided is true and correct.

By checking this box I know that I must notify the board if any information submitted on this form changes.

Date

My name is

My email is