Annual Compliance Reporting Form

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

RSOCertification 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:______

RSOCertification 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

aActivity of the nuclear substance in the sealed source on the reference date

bDate 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 EffectiveDose (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.