Instructions for completing the Employee's Dose History Summary (EDHS) Request Form

To ensure accurate completion of each entry and avoid unnecessary delays in processing your request please complete the information manually and FAX it to NDR at 613-957-0960.

Once completed and signed, this form shall be handled and stored at the level of Protected .

Information to be provided by each applicant

1. Please ensure that the following mandatory fields are correctly completed:
   • Company Name - name of the company you are representing
   • Company Address - complete address of the company you are representing
   • Contact Person Information - First and Last Name, E-mail, Telephone & FAX numbers (including the area code)
   • Request Date - follow the format: yyyy/mm/dd
2. Please indicate the type of request using the corresponding checkbox:
   • Select "Dose History Request for a Single Employee" if you are requesting information for one employee;
   • Select "Dose History Request for Multiple Employees" if you are requesting information for two or more individuals. In this case, please provide the consent for release of dose information for each employee (as indicated in Section 3) and a summary list with all the employees for whom you are requesting dose records.  Please use the template provided below, include Legal complete names, SIN(s) and the date of birth for each employee, and attach this summary information to the request.
   • Legal Name
     • First (Name) and Last (Name)
   • Social Insurance Number (SIN)
     • xxx xxx xxx
   • Date of Birth
     • yyyy/mm/dd
3. In order to process your request, the "Consent for release of employee's dose information" for each employee must be obtained. The NDR requires also that all fields be correctly filled in. Please be advised that any omissions or discrepancies identified in this section may result either in a delay in processing or a rejection of the request, until correct and complete information is provided.
   
   Note: Social Insurance Number (SIN), Last and First Name must be provided as indicated on the SIN card for each individual.
4. For security and confidentiality reasons, the NDR can only release Employee's Dose History Summary by traditional (regular) post mail or FAX.
   
   Indicate in the appropriate area if you would you like to receive the Employee's Dose History Summary by "FAX" or by "Post mail" and ensure that complete information is provided.
   
   Note: A Dose History Summary contains personal information; please ensure that you are comfortable in receiving your EDHS at the FAX number you provided.

Should the National Dose Registry (NDR) be unable to process your request due to missing, incomplete or illegible information, you will be asked to re-submit your request after being corrected accordingly.