I declare myself to be pregnant as of the date of completion of this form. I understand the following: Exposure to my unborn child from occupational exposure to radiation will not be allowed to exceed 4 mSv during the remainder of the pregnancy. Meeting the lower dose limit may require a change in job, or job responsibilities during my pregnancy but I will remain employed by the University of Alberta. I encouraged to speak with the Radiation Safety Officer about my radiation exposure as soon as possible. It is my responsibility to forward this form to the Radiation Safety Officer. I should inform the Radiation Safety Officer as soon as possible if I find out that I am not pregnant, or if for any reason my pregnancy has been terminated. Please complete the following: Name (first, middle, last) S.I.N. Due date (month, day, year) Telephone number Department Position Radionuclide Permit Holder Signature of Pregnant Worker Date For completion by Radiation Safety Officer I acknowledge receipt of the declaration of pregnancy for the above individual and have discussed with her the potential risks to the unborn child that could occur from radiation exposure. Name Telephone number Signature Date The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act for the purpose of identifying nuclear energy workers who are pregnant to explain exposure of radiation risks and determine associated changes to compensate for any risks, if required. Questions concerning the collection, use or disposal of this information should be directed to: Radiation Safety Officer Phone: (780) 492-5655.
I declare myself to be pregnant as of the date of completion of this form. I understand the following: Exposure to my unborn child from occupational exposure to radiation will not be allowed to exceed 4 mSv during the remainder of the pregnancy. Meeting the lower dose limit may require a change in job, or job responsibilities during my pregnancy but I will remain employed by the University of Alberta. I encouraged to speak with the Radiation Safety Officer about my radiation exposure as soon as possible. It is my responsibility to forward this form to the Radiation Safety Officer. I should inform the Radiation Safety Officer as soon as possible if I find out that I am not pregnant, or if for any reason my pregnancy has been terminated. Please complete the following: Name (first, middle, last) S.I.N. Due date (month, day, year) Telephone number Department Position Radionuclide Permit Holder Signature of Pregnant Worker Date For completion by Radiation Safety Officer I acknowledge receipt of the declaration of pregnancy for the above individual and have discussed with her the potential risks to the unborn child that could occur from radiation exposure. Name Telephone number Signature Date The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act for the purpose of identifying nuclear energy workers who are pregnant to explain exposure of radiation risks and determine associated changes to compensate for any risks, if required. Questions concerning the collection, use or disposal of this information should be directed to: Radiation Safety Officer Phone: (780) 492-5655.
nuclear-energy-worker-declaration-of-pregnancy.docx