This form letter is provided for convenience. To make a written declaration of pregnancy, fill in the blanks in this form letter, use a form letter the licensee has provided, or compose your own letter. Submit this to the Director of Compliance at OUCOD.
DECLARATION OF PREGNANCY
To: ________________________________________________
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 became pregnant in ____________________ (only the month and year need to 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 millisieverts) (unless that 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.
________________________________
(Your signature)
________________________________
(Your name printed)
________________________________
(Date)
8.13-8.13-11
Please contact Director of Compliance at the University of Oklahoma College of Dentistry for further guidance.
Further information about radiation safety can be found at the main office of University of Oklahoma Health Sciences Center, Office of Compliance: http://compliance.ouhsc.edu.
