Pregnant Worker Declaration

INSTRUCTIONS: This part of the evaluation is to be completed by the pregnant worker. After your form is received, Radiation Safety will evaluate your exposure history and make recommendations, which should enhance your efforts to minimize exposure to ionizing radiation during the balance of your pregnancy. You may request a confidential meeting with Radiation Safety to discuss these matters at any time by calling (410) 706-7055.

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Last 5 Digits Required
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Please provide your Physician's Name, Mailing Address and Phone Number.

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Please indicate the type(s) of machine(s) that will be used and describe your use of the machine(s) and provide the name of the person (authorized user) who is responsible for the radiation producing machine(s) below.

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Please list the radionuclide(s) and activity(ies) involved and describe your use of the material below. Be sure to provide the name of the person (authorized user) who is responsible for the radioactive material(s).

Describe your work involving radioactive material or radiation producing devices and describe the precautions you will employ to minimize exposure to ionizing radiation. You may wish to consult the person responsible for your radiation work when completing this section:

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Please provide the name, address and contact person (e.g., supervisor/Radiation Safety Officer, for the location(s) where radiation dosimetry is received or used.

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I give consent for my fetal dosimetry badge to be delivered with all other badges, and for any dose received on the badge to be reported on the same form as all others in that location. I understand that by doing this, others in my location may become aware that I have declared my pregnancy.

I understand the radiation dose to my embryo/fetus during my entire pregnancy will not be allowed to exceed 0.5 rem (5 millisievert) (unless that has already been exceeded between the time of conception and submitting this letter). I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy. I have read all information contained on this form and the Nuclear Regulatory Commission Guide 8.13, "Possible Health Risks to Children of Woman Who are Exposed to Radiation During Pregnancy."

If you have any questions about the information requested on this form or the Pregnant Work Program in general, please contact Radiation Safety at (410) 706-7055.

Declaration: I hereby certify that the above information is accurate to the best of my knowledge and ability to determine that no deliberate or willful omissions of composition or properties exist and that all known or suspected hazards have been disclosed and all infectious organisms/agents have been rendered nonviable.