National Dose Registry (NDR): Employee's Dose History Summary (EDHS) Request Form

Please follow the instructions provided when preparing your request in order to ensure accurate completion of each entry and avoid unnecessary delays in processing. The NDR will require up to 10 (ten) working days to evaluate and process any Employee's Dose History Summary request.

1 Client Section

• Company Name
• Date of request (yyyy/mm/dd)
• Company Address
• Contact Person Name
• Telephone number ( )
• E-mail

2 Employee's Dose History Summary Request Details

• Dose History Summary Request for a Single Employee
• Dose History Summary Request for Multiple Employees (provide a consent for release of dose information for each employee)

3 Consent For Release of Employee's Dose Information

• Legal Name (as it appears on your Social Insurance Number card)
  • First:
  • Last:
• Social Insurance Number (SIN)
• Date of Birth (yyyy/mm/dd)
• Gender
  • F
  • M
• Date of Request (yyyy/mm/dd)
• Applicant's Signature (mandatory)
• I authorize Health Canada, National Dose Registry to provide my radiation dose history summary to the above organization's contact person as indicated on this form.

4 Employee's Dose History Summary (EDHS) Return Instructions

For security and confidentiality reasons, the NDR can only release an Employee's Dose History Summary by traditional post mail or FAX. Please indicate your preference below. A Dose History Summary contains personal information; please ensure that you are comfortable in receiving your EDHS at the FAX number you provided.

• FAX: ( )
• Post Mail Address:

PRIVACY - The personal information you provide is collected under the authority of the Department of Health Act for the purpose of providing you with an employee's radiation dose history summary. Requests from a third party for an employee dose history will only be provided with the written consent of the employee. This collection of personal information is described in Info Source under the Personal Information Bank (PIB) HC PPU 080 - National Dose Registry for Occupational Exposures. Health Canada will be unable to process your request if you fail to complete the required fields in this request form. The Privacy Act gives you the rights of access to, correction of and protection of your personal information.