Contents
The North Carolina Rs 11 form is a critical document for individuals at North Carolina State University who are pregnant and may be exposed to occupational radiation. This form serves multiple purposes, including the voluntary declaration of pregnancy, the provision of essential information regarding prenatal radiation exposure, and the evaluation of dosimetry needs. The first section allows the individual to formally declare their pregnancy, providing personal details such as the estimated date of conception and relevant identification numbers. Following this declaration, the form outlines the instructions given to the employee, which cover the risks associated with prenatal radiation exposure, previous monitoring results, and the established fetal dose limits. Additionally, it emphasizes the importance of understanding the U.S. NRC Regulatory Guide 8.13, which offers guidance on prenatal radiation exposure. The third section addresses dosimetry evaluation, where the availability of fetal dosimetry devices is discussed, particularly for those likely to exceed the defined fetal dose limits. Lastly, the form includes an acknowledgment section, ensuring that the individual has comprehended the information provided and had the opportunity to ask questions. This comprehensive approach underscores the commitment to safety and informed decision-making for pregnant employees working in environments where radiation exposure is a concern.
Sample - North Carolina Rs 11 Form
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:_______________________________ |
Date: ________________ |
Radiation Safety Manual, Version VI, 2005
File Breakdown
| Fact Name | Fact Description |
|---|---|
| Form Purpose | The RS 11 form is used for declaring pregnancy to ensure the safety of pregnant employees exposed to radiation. |
| Governing Law | This form is governed by North Carolina Regulations for the Protection Against Radiation, specifically 15A NCAC 11. |
| Voluntary Declaration | Employees voluntarily declare their pregnancy, which is essential for managing radiation exposure risks. |
| Fetal Dose Limit | The form outlines a fetal dose limit of 0.5 rem during the gestation period for those exposed to occupational radiation. |
| Dosimetry Evaluation | Additional fetal dosimetry devices are available for individuals likely to exceed 10% of the fetal dose limit. |
| Information Provided | Information about prenatal radiation exposure risks and mitigation methods is provided to the individual declaring pregnancy. |
| Previous Monitoring Review | Previous personnel monitoring results may be reviewed with the individual, if available. |
| Questions Opportunity | Individuals have the opportunity to ask questions and receive answers regarding their radiation exposure. |
| Acknowledgments | The form requires acknowledgment that the information about radiation exposure has been discussed. |
| Version Information | The Radiation Safety Manual referenced in the form is Version VI, published in 2005. |
Discover Other Templates
North Carolina 28 - Employer compliance with filing this form is essential for the proper administration of workers' compensation benefits and protocols.
When dealing with real estate transactions, a common choice for property transfers is the simple Quitclaim Deed form, which provides a straightforward means of relinquishing property claims. This document is especially useful for individuals who need to transfer ownership without the complexities of title insurance or warranties.
Notice of Right to Have Exemptions Designated - Addresses the special exemptions for elderly or disabled debtors, reflecting societal values on protection and compassion.
Nc Long Form - Employees have a duty to accurately report their earnings to continue receiving the appropriate level of benefits.