Pregnancy Declaration
Radiologic Technology Program
I, the undersigned, have been informed of all risks and complications possible from engaging in the practice of
radiology while pregnant, and release the school and clinical facility from any responsibility for any complications
that may arise. Principles of Radiation Protection have been discussed. In accordance with the NRC’s regulations
at 10CFR 20.1208, “Dose to an Embryo/Fetus,” I am declaring that I am pregnant. I believe I became pregnant in
______________________________ (only the month and year need be provided). I will be expected to pay
$55.00 for the additional fetal badge required for my declaration of 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 dose has already been exceeded between the time of conception and submitting
this letter).
The following information has also been discussed and all questions answered to my satisfaction:
1. U.S. Nuclear Regulatory Research
“Instruction Concerning Prenatal Radiation Exposure” 6/99
2. NCRP Commentary #9
“Considerations Regarding the Unintended Radiation Exposure of the Embryo”, Fetus or Nursing Child.” 5/94
3. U.S. Nuclear Regulatory Research
“Instruction Concerning Prenatal Radiation Exposure.” 6/99
Name:
Signature: Date:
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