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I am responsible to make an appointment to speak with the Radiation Safety Officer about my radiation exposure as soon as possible. I am responsible to inform my supervisor as soon as practical if I find out I am not pregnant, or if for any reason my pregnancy is terminated. Signature of Pregnant Worker: ________________________ Date: __________________________ List any and all restrictions in job duties to limit dose to the unborn child. Indicate the controls that are required. Document the assessment of potential exposure and your understanding of the specific controls. Consult with the Radiation Safety Officer if necessary. Add lines if necessary.  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       TO BE COMPLETED BY THE RADIOISOTOPE PERMIT HOLDER: I acknowledge receipt of the declaration of pregnancy by signing this statement for the above individual and have discussed the potential risks to the unborn child that could occur from radiation exposure. 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