ANNUAL COMPLIANCE REPORTING FORM LICENSED ACTIVITY OPERATE A MEDICAL

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Annual Compliance Reporting Form

ANNUAL COMPLIANCE REPORTING FORM LICENSED ACTIVITY OPERATE A MEDICAL



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

Manufacturer

Model

Serial Number

Nuclear Substance

Nominal Activitya

Reference Dateb (yyyy/mm/dd)


Use

Storage




















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:




Number of Workers in each Effective Dose (mSv) Category

Dosimetry Service Provider

Maximum Individual Dose (mSv)

Number of Times Action Level Exceeded

(if applicable)


<0.50

0.50 to 1.00

1.01

to 5.00

5.01 to 20.00

>20.00

NEWs









Non-NEWs












Workload


Provide a detailed summary of the photon workload of medical accelerators in various modes of operation during the reporting period:


Manufacturer

and Model of

Prescribed Equipment





Serial Number

Room


Treatment

Non-treatment

Total

Approved Annual Workload

(Gy/year)

Conventional

IMRT

Dosimetry, QA

Maintenance and Servicing

Research/Other




Gy








MU











Gy








MU









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










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.


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