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DECLARATION OF PREGNANCY (Wright State University)

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THEDECLARATIONWILLBEKEPTCONFIDENTIAL
Declared Pregnancy Form Version:2015.1 Revised: 25 Feb 2015 University Radiaon Safety Office
UNIVERSITY RADIATION SAFETY OFFICE
DECLARATION OF PREGNANCY
Date(ofdeclaration):
To:WrightStateUniversityRadiationSafetyOfice
From(yourname):
ThiscompletedformletterisbeingsubmittedtodaytotheWrightStateUniversityRadiationSafety
OficeandistheoficialnotiicationtoWrightStateUniversityRadiationSafetyProgramthatIampreg-
nant.
IunderstandthisdeclarationofpregnancyisapersonalchoiceandoptionalunderWrightStateUni-
versity’sRadiationSafetyProgram.Iunderstandthatduringtheperiodofpregnancydeclaration,my
occupationallyallowedradiationdosewillbereduced500milliremtothefetus.Iunderstand,again
becauseofpersonalchoice,Imay“undeclare”mypregnancy,inwriting,atanytime.
Iprovidethefollowinginformationtoensureregulatoryrequirementsaremetandtoassistindeter-
miningifadditionalmonitoringorspecialprecautionsarenecessary.
RegardingMyExposuretoIonizingRadiation
Foranyquestions,contactmyworknumber: ormypersonalphone:
IamawaretheRadiationSafetyOficehascopiesoftheNuclearRegulatoryCommissionguide8.13,
“InstructionConcerningPrenatalRadiationExposure:”thatImayreviewandIcanalsoobtainacopy
fromtheCommission’swebsite:www.nrc.gov.IunderstandImayspeakwithamemberoftheRadia-
tionSafetyOficeaboutmyradiationexposure.TheRadiationSafetyOficerisopentoconsultationif
anyquestionsorconcernsarise.
I work with radioacve material under the supervision of:
Radionuclides I will be using during my pregnancy:
I work with radiaon generang equipment under the supervision of:
Radiaon Generang Equipment I will use during my pregnancy:
I am exposed to radiaon from the following radionuclides(s) or radiaon‐generang equipment but I
am not currently working with them (list):
I am currently issued the following personal monitoring dosimetry:
1 whole body dosimeter 2 whole body dosimeters hand (ring) dosimeter
I am currently not issued any radiaon monitoring dosimetry.
InformationRegardingMyPregnancy
Myestimateddateofconceptionis: Mydeliverydateisonorabout:
InformationRegardingMyDosimetry
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DECLARATION OF PREGNANCY (Wright State University)

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Completed 16 December 2020

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