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Click ‘Get Form’ to open the Q Pregnancy Release and x-ray consent form in the editor.
Begin by entering your name in the 'Patient Name' field, followed by your date of birth in the designated area.
Carefully answer the questions provided for females only. Start with question 1 regarding pregnancy status, followed by the date of your last period, birth control usage, and whether you are trying to conceive.
Review your answers to ensure accuracy. Your signature at the bottom confirms that you have read and understood all statements. Sign and date the form accordingly.
If required, a witness should also sign and date the form in the specified section.
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What is the ten-day rule and what is its status? It is important for radiology facilities to have procedures to determine the pregnancy status of female patients of reproductive age before any radiological procedure that could result in a significant dose to the embryo or fetus.
What happens if a pregnant woman is exposed to radiation?
Radiation exposure during pregnancy may have serious teratogenic effects to the fetus. Therefore, checking the pregnancy status before imaging women of child bearing age can protect against these effects.
What is the pregnancy rule in radiography?
A conservative approach used by some radiology facilities is to apply a 10-day rule only for examinations with the potential to deliver a high dose to the lower abdomen and pelvis, such as barium enemas and CT of the abdomen or pelvis. These facilities use a 28-day rule for all other examinations.
Why do they ask if youre pregnant before a CT scan?
A radiation worker who becomes pregnant should notify her department head or supervisor and the Radiation Safety Office (RSO) as early as possible. If the employee chooses not to declare the pregnancy to the RSO, additional controls and monitoring for her radiation exposure cannot be implemented.
Can a pregnant woman be around someone who had a CT scan?
Can a pregnant woman accompany a friend, partner or child who is having a scan? It is not desirable. Although the radiation dose from the person undergoing a scan is fairly low, it is desirable to keep the radiation exposure to the foetus as low as reasonably achievable.
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People also ask
What is a pregnant partners informed consent form?
The purpose of this form is to inform you of how you and your babys personal health information may be used or given to others so that you can decide whether to permit the use and disclosure (sharing) of you and your babys health information for the purposes stated in this form.
What is consent for X rays?
Consent can be given: verbally for example, a person saying theyre happy to have an X-ray. in writing for example, signing a consent form for surgery.
Related links
Declaration of Pregnancy | Environmental Health and Safety
This page provides answers to the most common questions and outlines OSU policy for pregnant radiation workers.
They must participate voluntarily and must provide written informed consent using an IRB-approved consent form. Requirements for human research in x-ray imaging
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