Fillable Declaration-of-Pregnancy-Form Letter For Declaring Pregnancy

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Declaration-of-Pregnancy-Form Letter For Declaring Pregnancy

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The Declaration-of-Pregnancy-Form Letter For Declaring Pregnancy form is 1 page long and contains:

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Letter For Declaring Pregnancy
This form letter is provided for your convenience. To make a declaration of pregnancy, you may
fill in the blanks in this form letter, or you may write your own letter.
Declaration of Pregnancy
To: Radiation Safety Office
In accordance with the NRC’s regulations 10 CFR 20.1208, “Dose to an Embryo\Fetus,” I am
declaring that I am pregnant. I believe I became pregnant in (mm/yy)
Current Supervisor or Dosimeter Series Code ___________________________
I understand the radiation dose to my embryo\fetus during my entire pregnancy will not be
allowed to exceed 0.5 rem (5 mSv) unless that dose has 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 responsibility during my pregnancy.
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Declaration-of-Pregnancy-Form Letter For Declaring Pregnancy

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Completed 3 March 2020

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