Annual Compliance
Reporting Form
Licensed Activity:
Operate a Medical Accelerator Facility (522)
January 2013
Annual Compliance Reporting Form
Operate a Medical Accelerator Facility (522)
Licence Number
CNSC Licence Number: _______________
Reporting Period
This Annual Compliance Report covers the 12 month period from
____/__/__ to ____/__/__
(yyyy/mm/dd) (yyyy/mm/dd)
Licensee Organization Information
Licensee Name: ________________________________________________________
Head Office/Legal Address: ____________________________________________________
City: _____________________ Province/State: ___________
Country: __________________ Postal/Zip Code: ________________
Licence Contact Person
(Person with authority to act for the licensee in dealing with the CNSC)
Name: _____________________________________________________
Title: _____________________________________________________
Mailing Address: ______________________________________________________
(if different from above)
City: ______________ Province/State: __________
Country: __________________ Postal/Zip Code: __________
Telephone: __________________ Alternate telephone: ______________
Facsimile: _____________
Email: ____________________________________________
Radiation Safety Officer (RSO)
Check box if RSO is same as licence contact
RSO Certification Number: __________________________
Name: _____________________________________________________
Title: _____________________________________________________
Mailing Address: ______________________________________________________
(if different from above)
City: ______________ Province/State: __________
Country: __________________ Postal/Zip Code: __________
Telephone:__________________ Alternate telephone: ______________
Facsimile: _____________
Email: ____________________________________________
Alternate Radiation Safety
Officer (if applicable)
Name: ____________________________________________________
Title: ____________________________________________________
Mailing Address: ______________________________________________________
(if different from above)
City: ______________ Province/State: __________
Country: __________________ Postal/Zip Code: __________
Telephone:__________________ Alternate telephone: ______________
Facsimile: _____________
Email: ____________________________________________
RSO Certification Number (if available): __________________________
Applicant Authority
Name: ____________________________________________________
Title: ____________________________________________________
Mailing Address: ______________________________________________________
(if different from above)
City: ______________ Province/State: __________
Country: __________________ Postal/Zip Code: __________
Telephone:__________________ Alternate telephone: ______________
Facsimile: _____________
Email: ____________________________________________
Signing Authority
Check box if signing authority is the RSO
Name: ____________________________________________________
Title: ____________________________________________________
Mailing Address: ______________________________________________________
(if different from above)
City: ______________ Province/State: __________
Country: __________________ Postal/Zip Code: __________
Telephone: __________________ Alternate telephone: ______________
Facsimile: _____________
Email: ____________________________________________
Inventory
Check box if there is no sealed sources in inventory
If applicable, provide detailed information for all sealed sources that are listed on this licence but are not in prescribed equipment.
Information should be presented in the format shown below.
Sealed Source |
Authorized Locationc |
Room Number |
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Manufacturer |
Model |
Serial Number |
Nuclear Substance |
Nominal Activitya |
Reference Dateb (yyyy/mm/dd) |
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Use |
Storage |
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a Activity of the nuclear substance in the sealed source on the reference date
b Date the activity was measured
c Site where the sealed source resides at the time of the report
Annual Effective Dose
Provide a detailed summary of the annual effective whole-body radiation doses received by nuclear energy workers (NEWs) and non-NEWs during the reporting period:
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Number of Workers in each Effective Dose (mSv) Category |
Dosimetry Service Provider |
Maximum Individual Dose (mSv) |
Number of Times Action Level Exceeded (if applicable) |
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<0.50 |
0.50 to 1.00 |
1.01 to 5.00 |
5.01 to 20.00 |
>20.00 |
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NEWs |
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Non-NEWs |
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Workload
Manufacturer and Model of Prescribed Equipment
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Serial Number |
Room |
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Treatment |
Non-treatment |
Total |
Approved Annual Workload (Gy/year) |
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Conventional |
IMRT |
Dosimetry, QA |
Maintenance and Servicing |
Research/Other |
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Gy |
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MU |
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Gy |
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MU |
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Transport Carriers
List all carriers employed to transport radioactive materials for the purposes of this licence during the reporting period:
Carrier Name |
Contact Telephone |
Name of Contact (if available) |
Location of Carrier City, Province |
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Declaration
I, the undersigned, having the authority to act for the licensee pursuant to section 15 of the General Nuclear Safety and Control Regulations, certify that all statements and representations made in this Annual Compliance Report and any supplementary pages appended to this report are true and correct to the best of my knowledge.
Name: _______________________________(please print)
Signature: _____________________________
Date: ____________________________
It is an offence under the Nuclear Safety and Control Act to knowingly make a false report.
NARHA ANNUAL CONFERENCE SCHOLARSHIP SCORING GUIDELINES
NOMINATION FORM FOR THE ANNUAL NURSE MENTOR PRIZE
NOTICE OF ANNUAL MEETING OF SHAREHOLDERS OF FREIGHTWAYS
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