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UNIVERSITY OF HOUSTON Radiation Safety Manual Declaration of Pregnancy Form 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. considered a declared pregnant woman* 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. 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. 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. 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. considered a declared pregnant woman* 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.

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