Harvard University
Radiation Protection Office
46 Oxford Street
Cambridge, MA 02138
Tel. (617)495-2060

Pregnancy Declaration Form


Date:

____________________
To:

Joseph P. Ring, Ph.D., Radiation Protection Officer
From:

____________________, Signature: ____________________
 

University Telephone: ______________  Social Sec. No: _______________
 

Working Under Permit Holder: ____________________
 

University Address: _____________________________

With this notice I inform you that I am pregnant or trying to become pregnant with an estimated conception date of ________ and an expected delivery date of ________. I understand the radiation exposure limit set by the Nuclear Regulatory Commission for embryo/fetus of the declared pregnant worker* is 500 mrem for the entire gestation period. In line with Harvard's policy of minimizing radiation exposure, I will continue to minimize my exposure and participate in a monitoring program for pregnant workers.

Please check the following as appropriate:

" I have questions related to the radiation protection of the embryo/fetus and would like to have a health physicist from the Radiation Protection Office contact me at __________.
" I do not wish to inform the principle investigator at this time.
" I have informed or will inform the principle investigator.
" I have questions related to the radiation protection of the embryo/fetus and will contact the Radiation Protection Office at 495-2060.
" I do not have questions related to the radiation protection at this time. I understand that I may contact the Radiation Protection Office if I have any questions in the future concerning this pregnancy.

* The NRC defines a declared pregnant woman as "a woman who has voluntarily informed her employer in writing of her pregnancy and estimated date of conception."