Declaration of Pregnancy Form

Please complete the following information and click the submit button. Doing so will send it to Environmental Health and Safety (EHS – 0824) at



am declaring that I am pregnant.

I believe I became pregnant on
My due date is approximately

I understand that my occupational radiation dose during my entire pregnancy will not be allowed to exceed 0.5 rem (5 millisieverts) (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. I understand I can withdraw this declaration.

Today's Date