FETAL DOSIMETRY
PROGRAM
Please
fill out this form if you wish to declare your pregnancy. REHS will issue a fetal radiation badge to
all pregnant workers who either work with radiation or are concerned because
they work in a radioactive materials lab.
These badges must be worn at waist level at all times while you are in
the controlled area. They will be
exchanged on the first of every month (or the first business day thereafter).
Please fill out all of the information below and return this
form to REHS via campus mail or fax at 732-445-3109. If you have any questions, please feel free to call REHS at
732-445-2550. All information
concerning your pregnancy will be kept confidential.
NAME:
______________________________________________________________________________
Last First Middle
Social Security Number ___________________________________
Net ID or ACS # _________________________________________
Date of Birth ________________ E-mail Address_________________________________________
Conception Date: ___________________________
Due Date: _________________________________
Home Address
_____________________________________________________________________
Home Phone _____________________________Office
Phone ______________________________
Office
Address______________________________________________________________________
Lab Location:
______________________________________________________________________
Principal Investigator’s
Name and Number: _______________________________________________
Signature _____________________________________ Date
___________________________
PLEASE CAMPUS MAIL OR FAX THIS FORM TO:
REHS
27 ROAD 1, BUILDING 4086
LIVINGSTON CAMPUS