Pregnancy Form

AUSTIN COMMUNITY COLLEGE
DIAGNOSTIC MEDICAL IMAGING - RADIOLOGY PROGRAM
 Pregnancy / Radiation Safety Protection
Verification Form
   
I verify by my signature below that:

1. I have notified the Austin Community College Diagnostic Medical Imaging - Radiology Program Coordinator of my pregnancy.
2. I have been advised by the Program Coordinator in regard to protective measures  as well as the risks associated with radiation exposure to the fetus.  I have also been advised to and/or have read the appendix to NCR 8.13.3
3. I have received an additional dosimeter that I an wearing at the level of the pelvis  to monitor the radiation dose to the fetus.
4. It has been explained to me that by wearing a 0.5 mm lead equivalent protective  apron, the dosage to the abdomen/pelvis can be reduced by more than 88 percent at 75 kVp.  It has also been explained to me that a lead apron with 1.0mm lead  equivalent should be worn when the beam is above 75 kVp.
5. I have had the opportunity to discuss questions concerning radiation safety  during my pregnancy with the Program Coordinator.  Furthermore, I understand that should additional questions arise, I may again consult with this individual.
    

(Initial the blanks)  

____________  I do understand the risks involved to myself and the fetus during
   my pregnancy in regard to pregnancy - related radiation safety.
  I elect to remain in the Program and adhere to the requirements as stated in Option # 1 of the attached Pregnancy Policy.

____________  I do understand the risks involved to myself and the fetus during my  pregnancy in regard to pregnancy - related radiation safety.
   I elect not to remain in the Program and that a leave of absence from the Program has been granted to me.  I understand my return is subject to space availability and I anticipate returning on or around the following date:_________________________

_________________________      _________________
Student’s Name Printed       Date
 

___________________________
Student’s Signature
 

___________________________      ___________________
Program Coordinator Signature        Date
 
 

AUSTIN COMMUNITY COLLEGE
DIAGNOSTIC MEDICAL IMAGING -  RADIOLOGY

PHYSICIAN’S AWARENESS OF PREGNANCY
 

____________________________  ___________         ____________________
Student Name (printed/typed)   Date of Birth         Social Security Number
 

The student named above is presently enrolled in the Diagnostic Medical Imaging- Radiology Program at Austin Community College.  Due to the nature of the Program, this student may be exposed ionizing radiation,or other health hazards (i.e. lifting, possible exposure to contagious disease, etc.). In order to determine the appropriate precautions, we need the following information:

1. Approximate date of conception   ______________________

2. Approximate date of expected delivery  ______________________

3. Present health status     ______________________

4. Will the student be under your care during her pregnancy ?

  __________Yes    ______________No

5. Have you informed her of the potential danger(s) involved in continuing her
 present career goal while pregnant?

  __________Yes   _____________No

6. Do you recommend her continuation in Clinical Education?

  __________Yes   _____________No

7. Do you recommend that she continue in the Program?

  __________Yes   ____________No

8. Recommended date maternity leave to begin:   _______________________

9. Recommended date Clinical Education may resume after delivery: _____________

NOTE:  A written release is required before this student may return to clinicals.
 

______________________  ________________________  _____________
Physician’s Name (printed)  Physician’s Signature Date