This form serves solely to document an employee’s voluntary declaration of pregnancy and that the employee has been informed of facts on occupational radiation exposure and on exposure to an embryo-fetus as required by law. Information on the form is taken from Section VIII of Radiation Safety in Dental Practice. If additional information on occupational exposure is requested by an employee, it can be found online at the Health Physics Society website.
Insert dental practice name and address at the top of the form as indicated. The supervising dentist should check the appropriate line in the first paragraph, then provide it to the declared pregnant employee for her review and signature. Maintain the form in the employee’s medical records file.