This information is required before a fetal dosimetry badge can be assigned. Completion of this form is voluntary, and you are in no way required to declare your pregnancy. Once you declare yourself pregnant, a fetal dosimetry badge will be assigned and closely monitored as required by State and Federal regulations. The fetal exposure limit will be enforced.

By submitting this form, I am formally notifying the MSU Radiation Safety Office of my pregnancy. I am requesting a fetal dosimeter with a regulatory exposure limit of 500 millirem during the gestational period. I understand that I may withdraw this declaration at any time for any reason, and the withdrawal must be submitted in writing.