DECLARATION OF PREGNANCY
ACKNOWLEDGMENT OF APPROPRIATE TRAINING
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 _________________