Dosimetry Services Agreement

National Dosimetry Services (NDS)
A Canadian Dosimetry Provider, Serving Canadian Interests

Information is protected when completed

National Dosimetry Services Use Only

• Client Services Section
  • Application Number:
  • Assigned to:
  • Service Identification:
  • Group Number:
  • Processed on:
  • Financial approval:
• Technical operations unit
  • Service Frequency:
  • Class Queue:
  • Dosimeter Type:
  • Assigned by:
  • Date:

Administrative Information

• Has your organization previously been on our service?
  • No
  • Yes
  • If yes, please indicate the previous group number: (format - Xnnnnn)
• Does your organization belong to the federal government?
  • No
  • Yes
  • If yes, please indicate your Department's organization and reference numbers:
    • Organization Number:
    • Reference Number:
• How Did you Hear About Us?
  • Trade Shows
  • Web site
  • I am a current customer
  • A customer referred me to you
  • Other (please specify)
• Why are you Using Dosimetry Services?
  • To enhance safety within the working environment
  • To meet regulatory requirements
  • To address personal health concerns
  • Other (please specify) :

Dosimeter Mailing Address

• Contact person:
• Name of organization:
• Department/section:
• Telephone:
• Address:
• City, Province:
• Fax:
• Postal Code:
• E-mail:

Exposure Report Mailing Address (if different)

• Same as dosimeter shipping address
• Other, please complete section below
  • Contact person:
  • Department/section:
  • Telephone:
  • Address:
  • City, Province:
  • Fax:
  • Postal Code:
  • E-mail:

Financial Correspondence Mailing Address (if different)

• Same as dosimeter shipping address
• Same as exposure report address
• Other, please complete section below
  • Contact person:
  • Department/section:
  • Telephone:
  • Address:
  • City, Province:
  • Fax:
  • Postal Code:
  • E-mail:

Technical Information

• Group classification(s) (please check all categories that apply):
  • Dental (Code: 1)
  • Hospital (Code: 2)
  • Industry and Commerce (Code: 3)
  • National Defence (Code: 4)
  • Mobile X-Ray Units (Code: 5)
  • Private Practitioner or Clinic (Code: 6)
  • Other Agencies and Research (Code: 7)
  • Special Projects (Code: 8)
  • Civil Defence (Code: 9)
  • Uranium Mines (Code: A)
  • Non-Uranium Mines (Code: B)
  • Nuclear Power Generation Station (Code: C)
  • Nuclear Fuel Facility (Code: D)
  • Luminizers (Code: E)
  • University (Code: F)
  • Government Laboratories (Code: G)
  • Industrial Radiology (Code: H)
  • Other (please specify):
• Service(s) required (please check all categories that apply)
  • Thermoluminescent (TLD)
  • Ring
  • Neutron
  • Uranium mines*
  • EPD
• Please check the radiation source in use:
  • X-ray
    
    If X-ray equipment is used, please state the operating voltage (kV), and its principle application.
    • Voltage (kV)
    • Voltage (kV)
  • Radioisotope
    
    If radioisotopes are used, please provide a representative list of radioisotopes, their approximate activities and usage (max use/month).
    • Becquerel (Bq)
    • Curie (Ci)
    • Becquerel (Bq)
    • Curie (Ci)

Annual subscription. (Processing fees are not included as part of the annual subscription fee. The Annual Subscription fee will be applied April 1^st of each year.)

Please check the service level

• GOLD - includes pre-loading of dosimeters into protective holders
• SILVER - no pre-loading
• BRONZE - no pre-loading

* Note: The Uranium Mines Service is offered as a pre-loaded service only. Therefore, the Annual Subscription service level that should be retained is the "Gold" Service.

Terms and Conditions

1. All dosimeters MUST be returned to NDS following the end of the scheduled wearing period, even if they have not been used. A customer who has not returned a dosimeter within three months following the end of the wearing period will be billed a late fee, as outlined under controlled fees in the Products, Services and Fees schedule.
2. The service is not transferable upon change of ownership.
3. The service remains in effect until written cancellation is received by the National Dosimetry Services. Your cancellation request MUST be received no later than 30 days prior to your next wearing schedule if registered under the Quarterly Service and 20 days prior if registered under the Semi-Monthly or Monthly Service otherwise any processing/handling charges incurred will be payable. The Annual Subscription Fee may apply.
4. The application MUST be signed by all representatives of the organization who are authorized to accept responsibility for payment of services.

Acknowledgement

I understand and agree to comply with the above terms and conditions.

• Name and title
• Signature
• Date : yyyy-mm-dd

Correspondence Language

• English
• French

Calendar Year / Mandatory Questionnaire

Please find below some background information related to this questionnaire which is required to be completed in order to assist the National Dosimetry Services (NDS) to determine your groups appropriate dosimeter wearing schedule. It is imperative for NDS to know who is your regulatory entity in order to confirm what regulatory requirements apply to your organization. Your cooperation is therefore needed to answer the questions cited on the next page.

Context

Occupational workers who have received or have a significant potential to receive a radiation dose in excess of 1 mSv in a calendar year are considered by the Canadian Nuclear Safety Commission (CNSC) -the regulatory entity who is responsible for regulating most users of radioactive material and high energy accelerators*** -  to be at an elevated risk level. CNSC requires the ability to monitor doses closely against regulatory dose limits.

The provinces and territories are in general, responsible for regulating users of X-rays and low energy accelerators. Exceptions are:  the Directorate of Nuclear Safety (DGNS) is responsible for X-ray users within the Department of National Defence (DND); Health Canada (specifically the Consumer and Clinical Radiation Protection Bureau) is responsible for regulating other users of X-rays within the federal government and those who fall under the provisions of the Canada Labour Code.

Regulatory requirements^{Footnote 1} are designed to ensure proper monitoring of individuals in certain occupations with the potential to receive higher doses. CNSC requires that such workers' monitoring periods closely parallel the calendar year. Other regulators are currently considering implementing similar requirements. To this end, it is necessary to classify our clients into two groups: those whose wearing periods must closely parallel the calendar year, and those whose wearing periods need not.

If you are unsure who your regulator is, please see the list of regulators found in Appendix C at the following Web site: www.hc-sc.gc.ca/ewh-semt/radiation/fpt-radprotect/guide-ld-eng.php

*** The exception is that the Department of National Defence (DND) is self-regulating through their Directorate of Nuclear Safety (DGNS).

If you have any questions in regards to this questionnaire, please contact us at 1-800-261-6689 or local 954-6689 or NDS-SND@hc-sc.gc.ca

Calendar Year / Mandatory Questionnaire

Please complete the following questionnaire. For more information, please refer to previous page.

If you are unsure of who your regulator is, please see the list of regulators found in Appendix C at the following Web site www.hc-sc.gc.ca/ewh-semt/radiation/fpt-radprotect/guide-ld-eng.php

• If you use x-rays, please answer questions 1 through 5
• If you use radioactive materials, please answer questions 6 through 9.
• If you have an accelerator, please answer questions 10 through 12.
• If you have any combination of the above, please answer the questions in the appropriate sections.

Questions

• X-ray users  Note: you will have only one(1) of the following Regulators
  • 1 Do the employees within your organization work with x-rays?
    • Yes
    • No
  • 2 Does your province or territory regulate your facility's use of x-ray producing equipment?
    • Yes
    • No
  • 3 Does the Department of National Defence regulate your facility's use of x-ray producing equipment?
    • Yes
    • No
  • 4 Does Health Canada regulate your facility's use of x-ray producing equipment?*
    • Yes
    • No
  • 5 Do you have staff who have received or who you believe are likely to receive (due to the type and quantity of work involving radiation) 1mSv or more per calendar year?**
    • Yes
    • No
• Radioactive material users
  • 6 Do the employees within your organization work with radioactive materials?
    • Yes
    • No
  • 7 Does your organization have a Licence from the CNSC for radioactive materials?
    • Yes
    • No
  • 8 Do you have a Licence /Permit from the DND for radioactive materials?
    • Yes
    • No
  • 9 Do you have staff who have received or who you believe are likely to receive (due to the type and quantity of work involving radiation) 1mSv or more per calendar year?**
    • Yes
    • No
• Accelerator users
  • 10 Does your facility use an accelerator with the capability to accelerate particles to 10 MeV or greater?
    • Yes
    • No
  • 11 Does your organization have a Licence from the CNSC for an accelerator?
    • Yes
    • No
  • 12 Do you have staff who have received or who you believe are likely to receive (due to the type and quantity of work involving radiation) 1mSv or more per calendar year?**
    • Yes
    • No

* Health Canada regulates Federal X-Ray facilities only such as x-ray facilities in a Federal Institution.

**If you are unsure of whether or not your group will receive more than 1 mSv in one year for your job classification, please refer to the National Dose Registry at http://www.hc-sc.gc.ca/ndr to review the latest Annual Report on Occupational Radiation Exposures in Canada.

New Users' Registration Form

Personal Employee Information (all information is mandatory and must be submitted in order to keep the national dose registry records updated).

• Social Insurance Number
• Surname
• Previous Surname (if applicable)
• Given Name(s) in full
• Sex
  • F
  • M
• Date of Birth (yyyy-mm-dd)
• Place of Birth (Province/Country)
• Job Classification Codes^{Footnote a}
• Wearing Location Codes^{Footnote b}
• TOTAL NUMBER OF DOSIMETERS REQUIRED

Use of Personal Information

The National Dosimetry Services collects, discloses, uses and processes personal information to submit and update personal records contained in the National Dose Registry, as per Regulatory Standard S-106. This regulatory activity ensures that the data to be transmitted to the National Dose Registry are in an acceptable format.

The regulatory documents permitting the National Dosimetry Services to request individual's social insurance number are listed below, as per the Canadian Nuclear Safety Commission and Provincial Radiation Dosimetry Review Committee regulatory standards.

• June 7, 1988 Cabinet Decision authorizing National Dose Registry to collect the social insurance number for those occupationally exposed to radiation. (File number: 9821-1-0)
  
  
• S-106 Revision 1, Regulatory Standard - Technical and Quality Assurance Requirements for Dosimetry Services in Canada, Appendix D.
  
  
• Canadian Nuclear Safety Commission Radiation Protection Regulations, Sections 9 and 10.

For further details, please refer to the web site of the  Office of the Privacy Commissioner of Canada at : www.priv.gc.ca/index_e.cfm

Privacy Statement

The National Dosimetry Services and the Government of Canada are committed to respecting the personal privacy of people who are in need of personal lifelong occupational monitoring for ionizing radiation.

Any information you provide is disclosed only to the National Dosimetry Services' employees and other officials who need it to process records to update the National Dose Registry, according to any of the legislation by which the National Dosimetry Services is governed. The National Dosimetry Services does not create individual profiles from the information that users provide. As well, we do not disclose the information to any party inside or outside the federal government unless authorized by law.

Mail your dosimetry service application to:

Health Canada,
Radiation Protection Bureau,
National Dosimetry Services,
775 Brookfield Road,
Address Locator 6301D,
Ottawa Ontario
K1A 1C1

or by Fax at 613-957-8698 or Toll Free at 1-800-252-6272.

If you have any questions about completing this service agreement, you may call our Customer Services at 613-954-6689 or Toll Free at 1-800-261-6689.

Table 1 - Job Classification Codes

Occupations	Codes
Administrator	0001
Aircrew	0410
Astronaut	0420
Chiropractor	0010
Chiropractor Assistant	0101
Dentist	0011
Dental Assistant	0026
Dental Hygienist	0025
Dental Therapist - Nurse	0027
Dial Painter	0040
Fuel Processor	0049
Fuel Processor - Production	0050
Fuel Processor - Maintenance	0051
Fuel Processor - Technical Support	0052
Fuel Processor - Administration	0053
Ground Transportation Driver	0310
Gynaecologist	0012
Industrial Radiographer	0045
Inspector	0075
Instructor (non-medical)	0041
Instrument Technician	0042
Janitorial Staff	0070
Laboratory Technician (Industrial)	0043
Laboratory Technician (Medical)	0013
Medical Physicist	0014
Medical Radiation Technologist	0017
Nuclear Medicine Technologist	0024
Nurse	0015
Orderly - Ward Aide	0022
Office Staff	0002
Other (Administration)	0004
Other (Industrial)	0048
Other (Medical)	0023
Other (Miscellaneous)	0074
Physician	0016
Radiation Therapist	0018
Radiologist (Diagnostic)	0019
Radiologist (Therapeutic)	0020
Safety Officer	0003
Salesperson	0071
Scientist - Engineer (Field)	0046
Scientist - Engineer (Laboratory)	0047
Security	0320
Speech Pathologist*	0028
Student	0072
Tradesman	0300
Veterinarian	0021
Veterinary Technician	0211
Visitor	0073
Petroleum Well Logger	0044

Classification Codes for Uranium Mines Workers Only

Occupations	Codes
Mill Maintenance	0680
Mill Worker	0690
Nurse	0615
Office Staff	0604
Surface Maintenance	0670
Surface Miner	0650
Surface Personnel	0602
Surface Support Worker	0660
Support Worker	0620
Underground Maintenance	0630
Underground Miner	0610
Underground Personnel	0601
Visitor	0603

Table 2 - Extremity Wearing Codes