Proof Of Pregnancy Form Pdf PDF Details

The Proof of Pregnancy PDF form serves a critical purpose in aligning occupational health and safety protocols with the needs of pregnant employees, specifically in environments where radiation exposure is a concern. By providing a structured means for employees to declare their pregnancy, this document plays a pivotal role in ensuring that the workplace becomes a safer place for both the expecting individual and their unborn child. The form, meticulously designed to comply with the Nuclear Regulatory Commission's (NRC) regulations, particularly at 10 CFR 20.1208 concerning "Dose to an Embryo/Fetus," embodies more than just a bureaucratic requirement. It encapsulates a proactive approach towards mitigating radiation exposure risks, underlining the permissible exposure limit of 0.5 rem (5 millisievert) throughout the course of the pregnancy. This limit safeguards the health and wellbeing of the developing fetus, potentially necessitating adjustments in the expectant employee's work role or responsibilities to adhere to safety guidelines. Detailed within this form are sections for the declarant’s signature, printed name, contact information, and the critical timing of the pregnancy's onset, underscoring the personalized and confidential nature of the process. Drafted to provide ease and clarity in declaring pregnancy, the form—while allowing for personalization—ensures uniformity in the communication between employees and their workplace safety coordinators, in this instance, addressed to the Dosimetry Coordinator at the Office of Environmental Health and Safety at UCSF. This approach not only fosters a supportive work environment but also emphasizes the organization's commitment to employee health and regulatory compliance.

QuestionAnswer
Form NameProof Of Pregnancy Form Pdf
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespdf filler proof of pregnancy, proof of pregnancy form pdf, blank proof of pregnancy form, get the planned parenthood pregnancy test form

Form Preview Example

FORM LETTER FOR DECLARING PREGNANCY

This form letter is provided for your convenience.

To make your written declaration of pregnancy, you may fill in the blanks in this form letter or you may write your own letter.

_____________________________________________________________________________________

DECLARATION OF PREGNANCY

To: Vicky Barberini, Dosimetry Coordinator, Box 0942

Office of Environmental Health and Safety, UCSF

In accordance with the NRC's regulations at 10 CFR 20.1208, "Dose to an Embryo/Fetus," I am declaring that I am pregnant. I believe I became pregnant in ________________________ (only

the month and year need be provided).

I understand the radiation dose to my embryo/fetus during my entire pregnancy will not be allowed to exceed 0.5 rem (5 millisievert) (unless that dose has already been exceeded between the time of conception and submitting this letter). I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy.

Your Signature: __________________________________

Your Name Printed: ________________________________

Today’s Date: ____________________________________

Your Phone Number: _______________________________

Eform-R002 Rev. April 2005; Feb. 2004

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