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Pregnancy declaration form 2026
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- Click ‘Get Form’ to open the pregnancy declaration form in our editor.
- Begin by entering your First and Last Name in the designated field at the top of the form.
- In the section where you declare your pregnancy, clearly write your name to voluntarily declare your pregnancy for monitoring purposes.
- Fill in your Approximate Due Date, Department, Phone number, and PSU ID # in the respective fields.
- Review the information provided to ensure accuracy. Once confirmed, proceed to sign by placing your full name in the signature line.
- Finally, submit the completed form by either printing it out or sending it via email as instructed at the bottom of the document.
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Related links
A woman may declare her pregnancy by notifying the licensee and/or registrant in writing of the pregnancy along with an estimated date of conception
I am voluntarily declaring that I am pregnant for the purposes of lowering occupational exposures received by my embryo/fetus.
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