In the realm of occupational health and safety within educational and research institutions, the North Carolina RS 11 form plays a crucial role, particularly at North Carolina State University (NCSU). This document outlines the procedure for voluntarily declaring pregnancy to NCSU's Radiation Safety Division, adhering to the state's protective regulations against radiation exposure. It not only serves as a declaration but also as a comprehensive guide for expectant employees on how to manage radiation exposure during pregnancy. The form is divided into critical sections, starting with the voluntary pregnancy statement, followed by instruction to the employee, which encompasses both oral and written information about the risks associated with prenatal radiation exposure and methods to minimize these risks. It reviews the employee's previous personnel monitoring results, if available, and outlines the fetal dose limit during gestation as prescribed by state regulations and the U.S. Nuclear Regulatory Commission. The dosimetry evaluation section discusses the use of additional fetal dosimetry devices for those with potential exposures exceeding 10% of the established limits, ensuring ongoing assessment and safety of the fetus through the pregnancy. Lastly, acknowledgments by the declarer and the Radiation Safety Officer affirm the information exchange and understanding of the risks involved. This form embodies NCSU's commitment to safety and regulatory compliance while supporting the well-being of its pregnant employees and their unborn children.
| Question | Answer |
|---|---|
| Form Name | North Carolina Form Rs 11 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | rs11 filling online pregnancy forms |
RS 11
NORTH CAROLINA STATE UNIVERSITY
ENVIRONMENTAL HEALTH AND PUBLIC SAFETY
RADIATION SAFETY DIVISION
PREGNANCY DECLARATION, INSTRUCTION & DOSIMETRY EVALUATION
SECTION 1 – VOLUNTARY PREGNANCY STATEMENT
I, ______________________________, voluntarily declare my pregnancy to North Carolina State
University Radiation Safety Division, as stated in North Carolina Regulations for the Protection Against Radiation, 15A NCAC 11. The estimated date of conception for this pregnancy is
______________ __________.
(Month) (Year)
_________________________________________________ |
NCSU ID#: ________________________ |
Department/ Principal Investigator |
(nine digits) |
_________________________________________________ |
|
Campus Box Number/Campus Telephone Number |
|
|
|
SECTION 2 – INSTRUCTION TO EMPLOYEE |
|
Oral and written information about prenatal occupational radiation exposure has been provided to the individual declaring pregnancy at this time. This information includes:
1.The risk associated with prenatal radiation exposure and methods available for minimizing risk.
2.A review of previous personnel monitoring results for the individual, if available.
3.The fetal dose limit of 0.5 rem during the gestation period for occupationally exposed declared pregnant workers.
4.The U.S. NRC Regulatory Guide 8.13 Instructions Concerning Prenatal Radiation Exposure.
5.An opportunity to ask questions and receive answers concerning the information provided.
[Fetal dose limits and time period information are taken from 15 NCAC 11. 1609, .1610, .1614 and the Radiation Safety Manual]
SECTION 3 – DOSIMETRY EVALUATION*
Additional fetal dosimetry devices are available for those individuals likely to receive fetal doses in excess of 10% of the established fetal dose limit, as proscribed in the 15 NCAC 11.1609, .1610, .1614. The utilization and application of such devices has been discussed with the individual declaring pregnancy at this time.
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Yes |
No |
1. |
Fetal dosimetry devices offered? |
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2. |
Fetal dosimetry devices accepted? |
*Note: Fetal dosimetry service is issued for the duration of the declared pregnancy.
SECTION 4 – ACKNOWLEDGMENTS
I acknowledge that the above information relating to occupational exposure to radiation has been discussed and an opportunity to ask questions was available.
Declarer: ___________________________________________ |
Date: ________________ |
Radiation Safety Officer:_______________________________ |
Date: ________________ |
Radiation Safety Manual, Version VI, 2005