University of Nebraska Medical Center Nebraska Medicine 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Print Name and Employee ID # in the designated fields at the top of the form.
3. Next, provide the Date of Conception (Mo/Yr) to declare your pregnancy officially.
4. Read through the exposure limits outlined in the document carefully. This ensures you understand your rights and responsibilities regarding radiation exposure during pregnancy.
5. Sign and date the form where indicated, confirming your declaration of pregnancy.
6. Fill in your Department and Zip code, along with Contact Information such as extension or email for follow-up.
7. Provide the Print Name and Signature of your Immediate Supervisor, along with their Date.
8. Finally, send the completed form to the Radiation Safety Office via email or postal service as instructed.

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