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Section I. Voluntary Declaration of Pregnancy
In accordance with the Texas regulations for Control of Radiation in 25 TAC 289.202 (m) (1), Dose equivalent to an embryo/fetus, I voluntarily declare that I am pregnant. My estimated date of conception is (Month and year) __________________ as regulatory required.
I understand that, the dose equivalent to my embryo/fetus during my entire pregnancy will not be allowed to exceed 0.5 rem (5 mSv) unless this limit has already been exceeded between the time of conception and the date of declaration as stated. By attesting this document, I understand that I have met the definition of a declared pregnant woman.
______________________ __________________
Signature and Date Employee/Student ID
____________________________________________
Name (Printed)
Section II. Rescinding Pregnancy Declaration
The pregnant worker may undeclare the above declaration in writing at any time without explanation and the dose monitoring will be discontinued and the applicable radiation worker occupational dose limits will apply.
I, _________________________________________, declare that I no longer wish to be considered a declared pregnant woman.
______________________________ _______________________
Signature and date Employee/Student ID
25 TAC 289.202 (c) (7) defines a declared pregnant woman as: A woman who has voluntarily informed the licensee, in writing, of her pregnancy and the estimated date of conception. The declaration remains in effect unless the declared pregnant woman voluntarily withdraws the declaration in writing or is no longer pregnant.
UNIVERSITY OF HOUSTON
Radiation Safety Manual
PAGE
December 2012
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