Last Name:     First Name:     MI:   

Soc. Sec. #:  (123-45-6789)    Birth Date:  (02/16/63)  

School:     Job Title:     

Division/Department:        Bldg.:  Rm. #:

Work Phone:  (410) 706-6281    Fax #:   

Email:   

Expected delivery date:  (02/16/63)       Assumed Conception Date:    (02/16/63)

Do you want a copy of this evaluation provided to your physician?  Yes  No    If yes, please provide physician's name, mailing address and phone number:
                        

  1. Will you operate a radiation producing device (e.g., x-ray machine)  Yes  No 
  2. Will you work in an area where you may be exposed to radiation from a radiation-producing device?  
     Yes  No

If you answered 'YES' to either of the above, indicate the type(s) of machine(s) that will be used and describe your use of the machine(s) and provide the name of the person (authorized user) who is responsible for the radiation producing machine(s) below.

Machine:  Diagnostic  Fixed  Portable  Therapeutic (explain below)  Dental
Type:Fluroroscopic  Fixed  Portable  Analytical (e.g., x-ray diffraction)  Other (explain below)

Authorized User: 

  1. Will you use of handle radioactive material?  Yes  No 
  2. Will you work in an area where you may be exposed to radiation from radioactive material?  Yes  No 

If you answered 'YES' to either of the above, list the radionuclide(s) and activity(ies) involved and describe your use of the material below.  Be sure to provide the name of the person (authorized user) who is responsible for the radioactive material(s).

Describe your work involving radioactive material or radiation producing devices and describe the precautions you will employ to minimize exposure to ionizing radiation.  You may wish to consult the person responsible for your radiation work when completing this section:

  1. Do you currently receive radiation dosimeters at UMAB?  Yes  No 
     
  2. If you are not being monitored for radiation exposure, you may participate in the dosimetry program by 'Yes'  Yes  No 

    If you are currently not being monitored for radiation exposure, please contact the Dosimetry Coordinator at 706- 6281 to receive your dosimeters.
     

  3. If you are receiving quarterly dosimeters (one every three months) you will be changed to a special series with monthly dosimeters effective immediately.  Contact the Dosimetry Coordinator at 706-6281 to receive your new dosimeters.
     
  4. In addition to your regular monthly dosimeters, you may request the addition of a fetal monitor to measure the exposure to the fetus.  If you wish a fetal monitor, 'Yes'  Yes  No
     
  5. Do you currently use radiation dosimeters (e.g., film badges) at any location other than UMAB?  Yes  No
    If  'Yes', provide the name, address and contact person (e.g., supervisor/Radiation Safety Officer, for the location(s) where radiation dosimetry is received or used.
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 does has already been exceeded between the time of conception and submitting this letter).  I also understand that meeting the lower does limit may require a change in job or job responsibilities during my pregnancy.

I have read all information contained on this form and the Nuclear Regulatory Commission Guide 8.13, "Possible Health Risks to Children of Woman Who are Exposed to Radiation During Pregnancy."
You must enter yes to acknowledge this paragraph:      (lower case only!)

Date Signed: 

  

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