Fetal Dosimetry Request

Fetal Dosimetry Request

The U.S. Nuclear Regulatory Commission (NRC) and the Minnesota Department of Health (MDH) have established a category of occupationally exposed individuals, the declared pregnant worker. The radiation dose equivalent to the embryo/fetus is 500 mrem for the entire gestation period. The State of Minnesota Rules require that following dose equivalent to the embryo/fetus, in any one month, not exceed 50 mrem.

Please complete the following form if you would like to request a fetal dosimeter.

Full Name (first and last)

Date of Birth

Email Address

When is your estimated due/guess date?

Do you already have dosimetry badges issued to you?

Yes

Current Department Information

Please provide the campus, department and supervisor you work for.

Where would you like the fetal dosimeter delivered each month you are monitored?

Fetal dosimeters are exchanged on a monthly basis, so this should be a location you will pickup your dosimeter from each month you are monitored.

Have you completed the UMN Declaration of Pregnancy Form?

Yes

If you would like to complete the UMN Declaration of Pregnancy form, please upload the document below.

Please upload your completed Declaration of Pregnancy form below.

NOTE: Completing this form is not required to receive fetal dosimeters.

Drag and drop files here or

Prenatal Education Documents

Please refer to the following documentation from the UMN Dosimetry website:

Minnesota Department of Health Prenatal Exposure Guide

UMN Prenatal Policy

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