Follow the steps to fill out the form accurately and effectively.

1. Click ‘Get Form’ button to access the form and open it in the application.
2. Begin by entering your first and last name in the designated field at the top of the form. This information identifies you as the individual submitting the declaration.
3. Next, clearly state your voluntary declaration of pregnancy in the provided text box. This declaration is important for monitoring any potential radiation exposure.
4. In the section regarding exposure monitoring, you may note whether you anticipate working in an environment with potential radiation exposure over 20 mrem (0.2 mSv) per month. If applicable, indicate your understanding to be issued a dosimeter specifically for monitoring.
5. Fill in your approximate due date in the appropriate space. This helps the Radiation Safety Officer address your specific monitoring needs.
6. Enter your department and phone number to ensure the Radiation Safety Officer can contact you if further information is needed.
7. Provide your PSU ID number in the given field. This unique identifier helps verify your status at Portland State University.
8. On the signature line, place your full name or electronic signature, certifying that the information you provided is accurate. By signing the form, you are consenting to share your protected health information with the Radiation Safety Officer.
9. Once all fields are completed, review your entries for accuracy. After reviewing, you can then save any changes, download a copy, print the form, or share it as needed.

Complete your form online today to ensure appropriate monitoring during your pregnancy.