The North Carolina RS 11 form is a declaration used by individuals at North Carolina State University to voluntarily report their pregnancy to the Radiation Safety Division. This form ensures that pregnant employees receive essential information about prenatal radiation exposure and the measures available to minimize risks. By completing the RS 11, individuals can engage in informed discussions about their health and safety in the workplace.
The North Carolina RS 11 form plays a crucial role in ensuring the safety and well-being of individuals who are pregnant and may be exposed to occupational radiation. This form is utilized by North Carolina State University’s Radiation Safety Division and serves multiple purposes. First, it allows individuals to voluntarily declare their pregnancy, which is important for monitoring and managing radiation exposure during this sensitive time. The form includes sections that provide essential information about the risks associated with prenatal radiation exposure and outlines the measures that can be taken to minimize these risks. It also details the fetal dose limits established for occupationally exposed pregnant workers, emphasizing the importance of maintaining exposure below 0.5 rem during the gestation period. Additionally, the RS 11 form includes a dosimetry evaluation section, offering the option for additional fetal dosimetry devices for those who may receive higher levels of exposure. By signing the form, individuals acknowledge that they have received and understood the information regarding radiation safety and have had the opportunity to ask questions. This comprehensive approach not only supports the health of the unborn child but also promotes a safe working environment for pregnant employees.
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RS 11
NORTH CAROLINA STATE UNIVERSITY
ENVIRONMENTAL HEALTH AND PUBLIC SAFETY
RADIATION SAFETY DIVISION
PREGNANCY DECLARATION, INSTRUCTION & DOSIMETRY EVALUATION
SECTION 1 – VOLUNTARY PREGNANCY STATEMENT
I, ______________________________, voluntarily declare my pregnancy to North Carolina State
University Radiation Safety Division, as stated in North Carolina Regulations for the Protection Against Radiation, 15A NCAC 11. The estimated date of conception for this pregnancy is
______________ __________.
(Month) (Year)
_________________________________________________
NCSU ID#: ________________________
Department/ Principal Investigator
(nine digits)
Campus Box Number/Campus Telephone Number
SECTION 2 – INSTRUCTION TO EMPLOYEE
Oral and written information about prenatal occupational radiation exposure has been provided to the individual declaring pregnancy at this time. This information includes:
1.The risk associated with prenatal radiation exposure and methods available for minimizing risk.
2.A review of previous personnel monitoring results for the individual, if available.
3.The fetal dose limit of 0.5 rem during the gestation period for occupationally exposed declared pregnant workers.
4.The U.S. NRC Regulatory Guide 8.13 Instructions Concerning Prenatal Radiation Exposure.
5.An opportunity to ask questions and receive answers concerning the information provided.
[Fetal dose limits and time period information are taken from 15 NCAC 11. 1609, .1610, .1614 and the Radiation Safety Manual]
SECTION 3 – DOSIMETRY EVALUATION*
Additional fetal dosimetry devices are available for those individuals likely to receive fetal doses in excess of 10% of the established fetal dose limit, as proscribed in the 15 NCAC 11.1609, .1610, .1614. The utilization and application of such devices has been discussed with the individual declaring pregnancy at this time.
Yes
No
1.
Fetal dosimetry devices offered?
2.
Fetal dosimetry devices accepted?
*Note: Fetal dosimetry service is issued for the duration of the declared pregnancy.
SECTION 4 – ACKNOWLEDGMENTS
I acknowledge that the above information relating to occupational exposure to radiation has been discussed and an opportunity to ask questions was available.
Declarer: ___________________________________________
Date: ________________
Radiation Safety Officer:_______________________________
Radiation Safety Manual, Version VI, 2005
When filling out and using the North Carolina Rs 11 form, there are several important points to consider: