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Instructions:
Please complete and return the attached information page
Please return this form by 15 March 2005 to:
Attention: Ms. Amy Doyle
Health Canada
Radiation Protection Bureau
Radiation Surveillance and Health Assessment Division
775 Brookfield Road, AL 6302D1
Ottawa, Ontario, K1A 1C1
FAX: 613-957-1089
E-Mail: amy_doyle@hc-sc.gc.ca
1. Organization Information:
Contact Name: ________________________________________
Organization: _________________________________________
Address: _____________________________________________
____________________________________________________
Phone: ______________________________________________
Fax: ________________________________________________
E-mail: ______________________________________________
| Whole Body | (Scheduled at client's convenience.) | YES | NO |
| Lung | (Scheduled at client's convenience.) | YES | NO |
| Thyroid | (Scheduled at client's convenience, subject to phantom) |
YES | NO |
| Tritium Urinalysis | May 2006 | YES | NO |
| Tritium/Carbon-14 Urinalysis | June 2006 | YES | NO |
| Fission/Activation Products Urinalysis | October 2006 | YES | NO |
| Carbon-14 Urinalysis | November 2006 | YES | NO |
| Uranium Urinalysis | March 2007 | YES | NO |
| Electronic (PDF File) (e-mail address required) |
Paper |
| Yes | No |