Name of pregnant worker_____________________________ SS#_____________________

Name of Sublicensee ________________________________ Lic.#_____________________

Department __________________ Labs(s)___________________________________________

I understand that it is the responsibility and choice of the individual to inform her sublicensee of a suspect or actual pregnancy. Accordingly, I do declare my pregnancy or intent to become pregnant and do request appropriate dosimetry monitoring. My dose limits and possible work restrictions have been explained to me. My sublicensee has provided me with specific training/information concerning radiation hazards to a fetus and associated potential reproductive abnormalities.

My estimated date of conception ____________________________.

Signature of worker______________________________________ Date ___________________

Signature of Sublicensee _____________________________________ Date _________________