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 848-445-2550.  All information concerning your pregnancy will be kept confidential. Questions? Contact Debbie Hrabinski

 

 

 

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:

 

Rutgers Environmental Health and Safety
Rutgers, The State University of New Jersey
27 Road 1
Bldg. 4086 Livingston Campus
Piscataway, NJ 08854-8036

PHONE 848-445-2550

FAX 732-445-3109

 

Last Updated:2/18/09
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