Pregnancy Forms

Pregnancy Forms
Please Select One of the Following *

Click this link to read important information about declaration of pregnancy

I have voluntarily made the decision to permit application of the embryo/fetal dose limits specified by the Nuclear Regulatory Commission (NRC) in Title 10 Code of Federal Regulations Part 20.1208 (10 CFR 20.1208) or the State of Michigan Ionizing Radiation Rules (R333.5059) as applicable.

Click this link to read important Information about Revocation of Pregnancy Declaration

I wish to formally notify Radiation Safety Service (RSS) that, as of this date I am revoking the Declaration of Pregnancy I filed with RSS. Included with this notice are any unreturned fetal dosimeters that were still in my possession. Please arrange to end the issuance of any additional fetal dosimeters.

I have read and understand the written material regarding the potential health effects from exposure to ionizing radiation published in Regulatory Guide 8.13 by the Nuclear Regulatory Commission and distributed by RSS. I also have read and understand the written explanatory information on the reverse side of this form. The decision to revoke my prior declaration of pregnancy to Radiation Safety Service is a personal choice which I have made freely.

I understand that by making this declaration, the fetal dose limits specified in 10 CFR 20.1208 will no longer be applicable for any remaining period of gestation. This revocation terminates any previous restrictions on work I perform using radioactive materials or other sources of ionizing radiation, that had been imposed by RSS, for the sole purpose of ensuring compliance with the embryo/fetal dose limits specified in 10 CFR 20.1208.

Click this link to read important information about expiration of declaration of pregnancy

I wish to formally notify Radiation Safety Service (RSS) that the Declaration of Pregnancy I filed with RSS is expired due to (check one and complete requested information): *
Participant Information
I am voluntarily submitting this Declaration of Pregnancy to inform Radiation Safety Service (RSS) that I am pregnant.
Acknowledgement *
Limitations

The Declaration of Pregnancy Form (RSS-105A), the Revocation of Declaration of Pregnancy Form (RSS-105B) and the Pregnancy Declaration Expiration Form (RSS-105C) serve the sole purpose of providing the means of election and choice in the compliance with NRC and State dose limit and regulations. It does not serve as actual or implied notice to any other department or unit within the University of Michigan regarding the declarant's physical status or condition.

Privacy

The information contained in the Declaration of Pregnancy Form (RSS-105A), the Revocation of Declaration of Pregnancy Form (RSS-105B) and the Pregnancy Declaration Expiration Form (RSS-105C) constitutes a record subject to the confidentiality provisions of applicable federal and/or state privacy laws and becomes part of the declarant's confidential record with RSS.

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