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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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, 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.