Instructions for completing the Personal Dose History Summary (PDHS) 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. In order for the NDR to process your request adequately, i.e. "releasing of personal dose information", a signature from each applicant must be obtained. The NDR also requires that all fields be correctly filled in.
   
   Please be advised that any omissions or discrepancies identified in this section may result either in the rejection of the request or delay in processing, 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.
2. 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 to receive your PDHS 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.