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Form Letter for Declaring Pregnancy
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| THIS FORM LETTER IS PROVIDED FOR YOUR CONVENIENCE. TO MAKE YOUR WRITTEN DECLARATION OF PREGNANCY, YOU MAY FILL IN THIS ONLINE FORM. YOU MAY USE THIS FORM LETTER THAT THE LICENSEE HAS PROVIDED TO YOU, OR YOU MAY WRITE YOU OWN LETTER. |
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| IN ACCORDANCE
WITH THE NRC'S REGULATIONS AT 10 CFR 20.1208, "DOSE TO AN EMBRYO/FETUS",
I AM DECLARING THAT I AM PREGNANT. |
| I BELIEVE I BECAME PREGNANT IN
(Only the month and year need be provided). |
| 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 THE DOSE 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. |
| Signature: _____________________________________ |
Print Name: _________________________________________ |
Date: ________________ |