Declaration of Pregnancy Form

The form letter below is provided for your convenience. To make your declaration of pregnancy, simply complete the form. You may also write your own letter.

Declaring Pregnancy

To Supervisor/AU:*
DECLARATION OF PREGNANCY

In accordance with the Nuclear Regulatory Commission 10 CFR 20.1208, "Dose to an Embryo/Fetus," and State regulations, I am declaring that I am pregnant.
I believe I became pregnant in (only month and year):*
I currently wear a dosimeter badge.
- Yes
- No
Confidentiality
- My pregnancy is confidential, please add it to the fetal badge confidential sub-account
- My pregnancy is not confidential, please add my fetal badge to my regular sub-account. It can be delivered to my badge group leader
I understand that my occupational radiation dose during my entire pregnancy will not be allowed to exceed 0.5 rem (5 milliseverts) (unless that dose has already been exceeded between the time of conception and submitting this letter). I am also aware of that the radiation exposure to the embryo/fetus of a declared pregnant woman should not exceed an ALARA action level of 50 mrem per month. I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy.
If I find out that I am not pregnant, or if my pregnancy is terminated, I will promptly inform you in writing that my pregnancy has ended.
Department:*
Phone Number:*
Email:*
Signature:*
Date:*
Phone
This field is for validation purposes and should be left unchanged.

Declaring Pregnancy

DECLARATION OF PREGNANCY

In accordance with the Nuclear Regulatory Commission 10 CFR 20.1208, "Dose to an Embryo/Fetus," and State regulations, I am declaring that I am pregnant.

If I find out that I am not pregnant, or if my pregnancy is terminated, I will promptly inform you in writing that my pregnancy has ended.