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Pregnancy declaration form

Pregnancy declaration form 2026

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The document is a Pregnancy Declaration Form for employees to voluntarily declare their pregnancy to ensure monitoring of radiation exposure to the embryo/fetus. It outlines the process for obtaining a fetal dosimeter, the radiation exposure limits for declared pregnant women, and provides contact information for the Radiation Safety Officer (RSO) for further assistance.

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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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