The Declaration of Pregnancy Form (RSS-105A) provides the formal means by which a pregnant occupational radiation worker voluntarily notifies Radiation Safety Service (RSS) of her choice to authorize the application of federal and/or state radiation dose limits to an embryo/fetus as a condition of her radiation related work at the university of Michigan. A declaration of pregnancy to the Department of Occupational Safety & Environmental Health - Radiation Safety Service can only be made by use of this form. Complete and submit this form only if you knowingly and voluntarily intend to declare your pregnancy to RSS.

The choice of whether to declare one's pregnancy is a personal one and is to be an informed one. A pregnant occupational radiation worker needs to be cognizant of information supplied by the NRC, the University of Michigan Radiation Policy Committee (RPC) and RSS as to the potential health effects from radiation to herself and to an embryo/fetus. RSS supplies written instructional material discussing such potential effects and will assist the pregnant worker in understanding the material contained therein so as to allow her to make an informed choice.

The Revocation of Pregnancy Declaration Form (RSS-105B) provides the formal means by which a pregnant occupational radiation worker voluntarily notifies Radiation Safety Service of her choice to revoke her previous election to apply federal and/or state radiation dose limits to an embryo/fetus as a condition of her radiation related work at the University of Michigan. Notice of revocation of declaration of pregnancy to the Department of Occupational Safety & Environmental Health - Radiation Safety Service (RSS) can only be made by use of this form. Complete and submit this form only if you knowingly and voluntarily intend to revoke your previous declaration of pregnancy to RSS.

The choice of whether to declare one's pregnancy is a personal one. No explanation for the revocation need be given. The choice also is to be an informed one. A pregnant occupational radiation worker needs to be cognizant of information supplied by the NRC, the University of Michigan Radiation Policy Committee (RPC) and RSS as to the potential health effects and will assist the pregnant worker in understanding the material contained therein so as to allow her to make an informed choice. It is important to understand that revocation does not terminate or otherwise affect other applicable federal and/or state imposed dose limits established by regulation to protect occupationally exposed individuals. If you have any questions or concerns, please contact RSS at 764-4294 before completing and submitting this form. Revocation of Pregnancy Declaration differs from Expiration and Lapse. Those differences are explained below:

Expiration - a declaration of pregnancy automatically expires when the associated condition of pregnancy actually ceases or upon termination of employment as an occupational radiation worker with the University of Michigan. A declared pregnant worker should provide RSS with a signed and dated written notice of the expiration of the declaration of pregnancy. This can be done by completing and submitting a Pregnancy Declaration Expiration Form (RSS-105C).

Lapse - RSS reserves the option to deem that a declaration of pregnancy has lapsed and no longer is in effect on the earlier of either: 1) 60 days after the estimated date of delivery designated by the declarant on the form of declaration; or 2) one year after the date of receipt of the declaration form at RSS offices.

This form is used by a declarant to notify Radiation Safety Service (RSS) that a Declaration of Pregnancy that had been filed with RSS has expired. Declarations expire when either the condition of pregnancy which prompted the original declaration has ceased or the declarant is no longer employed as an occupational radiation worker with the University of Michigan. For the purposes of expiration, a declarant is no longer an occupational radiation worker when that person has either permanently terminated employment with the University of Michigan or has taken a position of employment at the University with job duties that do not include any work with radioactive materials or devices which generate ionizing radiation.

In addition, a declarant may elect optionally to notify RSS of the expiration of a Declaration of Pregnancy if the declarant, for any reason, is taking an extended period of absence from her employment (e.g. pregnancy leave of absence, vacation, etc.) or a temporary job reassignment during either of which she will not be engaged in work activities involving the use of radioactive materials or ionizing radiation generating devices at the University of Michigan until after the condition of pregnancy has ceased. In such cases, the declarant must indicate on the RSS-105C form the date on which the period of absence or reassignment will commence. The expiration will formally take effect on that date. If no date is indicated, the expiration will not take effect and the original Declaration of Pregnancy will remain in effect until a properly completed RSS-105C form is submitted or until automatic expiration of lapse (see below).

The application of federal and/or state radiation dose limits to an embryo/fetus ceases with expiration of the Declaration of Pregnancy. Expiration differs from revocation in that revocation is a knowing and voluntary election on the part of the declarant to terminate the application of embryo/fetal radiation dose limits regardless of whether the condition of pregnancy has ceased or work with radioactive materials or radiation generating devices has ceased. See below for additional information.

Expiration - a declaration of pregnancy automatically expires when the associated condition of pregnancy actually ceases or upon termination of employment as an occupational radiation worker with the University of Michigan. A declared pregnant worker should provide RSS with a signed and dated written notice of the expiration of the declaration of pregnancy. This can be done by completing and submitting a Pregnancy Declaration Expiration Form (RSS-105C).

Lapse - RSS reserves the option to deem that a declaration of pregnancy has lapsed and no longer is in effect on the earlier of either: 1) 60 days after the estimated date of delivery designated by the declarant on the form of declaration; or 2) one year after the date of receipt of the declaration form at RSS offices.