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Get the free UMHHC - Declaration of Pregnancy Form (RSS-105A) - oseh umich

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This form serves as a formal means for pregnant occupational radiation workers to notify Radiation Safety Service (RSS) of their pregnancy and authorize the application of radiation dose limits to
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How to fill out UMHHC - Declaration of Pregnancy Form (RSS-105A)

01
Obtain the UMHHC - Declaration of Pregnancy Form (RSS-105A) from the appropriate source.
02
Fill in your personal details such as full name, date of birth, and address at the top of the form.
03
Provide your insurance information, including the policy number and provider details.
04
Indicate the expected due date of your pregnancy in the designated section.
05
Confirm your physician's name and contact information.
06
Review the form for accuracy and completeness.
07
Sign and date the form at the bottom.

Who needs UMHHC - Declaration of Pregnancy Form (RSS-105A)?

01
Women who are expecting and need to notify their healthcare provider or insurance company of their pregnancy.
02
Patients seeking maternity benefits from insurance providers.
03
Individuals planning to receive prenatal care services.
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Under NRC's definitions (10 CFR 20.1003), a declared pregnant worker is a worker who has voluntarily informed the employer, in writing, of the pregnancy and the estimated date of conception.
These regulations establish the Declaration of Pregnancy, a voluntary written notification of pregnancy submitted to Radiation Safety. With the Declaration of Pregnancy, the worker grants consent to her employer to limit the dose to 0.5 rem (5 mSv) throughout the pregnancy.
The 10-day rule was established by the International Commission on Radiological Protection to minimize the potential for performing x-ray exams on pregnant women. The basis of the rule was to do abdominal and pelvic x-ray exams only during the 10 days following the onset of .
With the Declaration of Pregnancy, the worker grants consent to her employer to limit the dose to 0.5 rem (5 mSv) throughout the pregnancy. If no declaration is submitted, then the dose limits for the worker remain unchanged (whole body dose limit = 5rem/yr (50mSv/yr)).
A radiation worker who becomes pregnant should notify her department head or supervisor and the Radiation Safety Office (RSO) as early as possible. If the employee chooses not to declare the pregnancy to the RSO, additional controls and monitoring for her radiation exposure cannot be implemented.
Declaration of pregnancy is voluntary and involves the completion of a written declaration that is submitted to the Radiation Safety Office. Upon notification of pregnancy, the RSO will provide instruction as applicable, on the risks of radiation exposure to the embryo/fetus of the worker.

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The UMHHC - Declaration of Pregnancy Form (RSS-105A) is a document used to officially declare a pregnancy for administrative and healthcare-related purposes within the University of Michigan Health System.
Individuals who are pregnant and seeking maternity benefits or services through the University of Michigan Health System are required to file the UMHHC - Declaration of Pregnancy Form (RSS-105A).
To fill out the UMHHC - Declaration of Pregnancy Form (RSS-105A), you need to provide personal identification information, details about your healthcare provider, and the estimated due date of the pregnancy. Ensure that all sections are completed accurately before submission.
The purpose of the UMHHC - Declaration of Pregnancy Form (RSS-105A) is to formally register a pregnancy to ensure that the individual receives appropriate maternity care and benefits during pregnancy and after childbirth.
The information that must be reported on the UMHHC - Declaration of Pregnancy Form (RSS-105A) includes the expecting individual's full name, contact information, provider details, and the expected delivery date.
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Declaration of Pregnancy Radiation Safety University of Michigan Dosimetry Program Nuclear Regulatory Commission fetal monitoring ionizing radiation pregnancy declaration health effects confidentiality

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