Massachusetts college of pharmacy & health sciences radiation therapy program school of Medical Imaging & Therapeutics Contact Information



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MCPHS Pregnancy Declaration


MCPHS Radiation Safety

How to and Declare Your Pregnancy?
In order to start this protection program, you must declare your pregnancy with your Instructor. A simple form is provided for you to declare your pregnancy. You must provide your name, a declaration that you are pregnant, the estimated date of conception (only the month and year need be given), and the date that you gave the form to the Instructor. All of this information is noted on the form. You may also write your own letter if you prefer.

• You do not need to provide documented medical proof that you are pregnant.

• Regulations require that the MCPHS receive the declaration in writing.

• Even if you are visibly pregnant, the lower dose limits do not apply until pregnancy is declared in writing.

• The choice to declare pregnancy, and thereby work under the lower dose limits is your choice. The College cannot direct you to make this declaration.

• If you are planning to become pregnant (but are not yet pregnant), and sign a declaration, the lower limits will not apply until you declare in writing that you are pregnant.

• Should you miscarry or discover that you are not pregnant, please notify the Instructor at your earliest opportunity.

• After the birth of your child, you must notify the Instructor that you have given birth so that embryo/fetal monitoring can be canceled and your normal exposure limits can be reinstated.

• You can revoke your declaration of pregnancy at any time, even if you are still pregnant by contacting the Instructor.

Monitoring the Radiation Dose to Your Embryo/Fetus
A special monitoring program has been developed to assist you and your Instructor with monitoring your radiation dose:

• Once pregnancy is declared, an extra dosimeter or film badge will be provided by the MCPHS’s Radiation Safety Officer to monitor the exposure to your embryo/fetus.

• Wear the dosimeter clipped on outer clothing under the lead apron if a lead apron is worn. The dosimeter should be worn at waist level at the location of your embryo/fetus at the part of the body that could receive the highest radiation exposures. This will usually be the front of your body.

• A special report will be provided once a month so that both you, and your instructor, can track your monthly doses. Radiation Safety Officer also independently reviews these reports.

• If you have any questions about the reports, or how to properly wear the dosimeter, please contact the MCPHS Radiation Safety Officer at 617-732-2861.

What are the health risks from radiation exposure to the embryo/fetus?

During certain stages of development, the embryo/fetus is believed to be more sensitive to radiation damage than adults. Studies of atomic bomb survivors exposed to acute radiation doses exceeding 20 rads (0.2 Gy) during pregnancy show that children born after receiving these doses have a higher risk of mental retardation. Other studies suggest that an association exists between exposure to diagnostic x-rays before birth and carcinogenic effects in childhood and in adult life. Scientists are uncertain about the magnitude of the risk. Some studies show the embryo/fetus to be more sensitive to radiation-induced cancer than adults, but other studies do not. In recognition of the possibility of increased radiation sensitivity, and because dose to the embryo/fetus is involuntary on the part of the embryo/ fetus, a more restrictive dose limit has been established for the embryo/fetus of a declared pregnant radiation worker. See Regulatory Guide 8.13. "Instruction Concerning Prenatal Radiation Exposure."



If an occupationally exposed woman declares her pregnancy in writing, she is subject to the more restrictive dose limits for the embryo/fetus during the remaining of the pregnancy. The dose limit of 500 mrems (5 mSv) for the total gestation period applies to the embryo/fetus and is controlled by restricting the exposure to the declared pregnant woman. Restricting the woman's occupational exposure, if she declares her pregnancy, raises questions about individual privacy rights, equal employment opportunities, and the possible loss of income. Because of these concerns, the declaration of pregnancy by a female radiation worker is voluntary. Also, the declaration of pregnancy can be withdrawn for any reason, for example, if the woman believes that her benefits from receiving the occupational exposure would outweigh the risk to her embryo/fetus from the radiation exposure.


CONFIDENTIAL

MCPHS

VOLUNTARY DECLARATION OF PREGNANCY FOR RADIATION WORKERS
I. DECLARATION OF PREGNANCY


Name of Individual




Social Security Number




Date of Conception (Mo/Yr)




By providing this information to my immediate supervisor/Instructor, in writing, I am declaring myself to be pregnant as of the approximate date shown above. Under the provisions of 10 CFR Part 20.1208 I understand that my exposure will not be allowed to exceed 5 mSv (500 mRem) during my pregnancy, from occupational exposure to radiation. I understand that this limit includes exposure I have already received. If my estimated exposure since the above approximate date of conception has already exceeded 5 mSv (500 mRem), I understand that I will be limited to no more than 0.5 mSv (50 mRem) for the remainder of my pregnancy. If I should find out that I am not pregnant, or if my pregnancy ends, I will inform my supervisor as soon as practical.

Signature of Individual




Date Signed





II. DESCRIPTION OF CURRENT WORK WITH IONIZING RADIATION


Source of Ionizing Radiation (equipment):
Isotope:



III. RECEIPT OF DECLARATION OF PREGNANCY


Name of Supervisor/Instructor




I have received notification from the above named woman that she is pregnant. I have explained to her the potential risks from exposure to radiation as provided in Regulatory Guide 8.13, Revision 3. I have evaluated her prior exposure and established appropriate limits to control the dose to the developing embryo/fetus in accordance with limits in 10 CFR part 20.1208. I have explained to her options for reducing her exposure to as low as reasonably achievable (ALARA).

Signature of Supervisor/Instructor




Date Signed





ACCEPTANCE OF POLICY FORM 2011-2012



Name________________________

ACCEPTANCE OF RT STUDENT HANDBOOK



I, ______________________________, acknowledge that I have received and am responsible for understanding and complying with the policies stated in the Radiation Therapy Student Handbook. I understand that I may contact Dr. Susan Belinsky at (617) 732 2261 to ask questions regarding the policies contained therein.

_________________________________

Student Signature Date
ACCEPTANCE OF RT DIRECT SUPERVISION POLICY
I, ______________________________, acknowledge that I have received and am responsible for understanding and complying with the policies stated in the Radiation Therapy Student Handbook. I understand that students are never to administer radiation without the direct supervision of a licensed radiation therapist.
ACCEPTANCE OF RT PREGNANCY POLICY
I, _________________________________________, acknowledge that I have received and am responsible for understanding and complying with the pregnancy policies stated in the Radiation Therapy Student Handbook. I understand that I may contact Dr. Susan Belinsky at (617) 732-2261 to ask questions regarding the policies contained therein.

_________________________________________

Student Signature Date
ACCEPTANCE OF ACADEMIC HONOR POLICY
I,_______________________________________, acknowledge that I have received and am responsible for understanding and complying with the honor system policy stated in the Radiation Therapy Student Handbook. I understand that I may contact Dr. Susan Belinsky at (617) 732-2261 to ask questions regarding the policy contained therein.

__________________________________________

Student Signature Date Revised 5/04
ACCEPTANCE OF CLINICAL TRAVEL POLICY
I,_________________________________, acknowledge that I have received and am responsible for understanding and

complying with the policies stated in the Radiation Therapy Student Handbook. I understand that all travel expenses to and from clinical are my responsibility.
__________________________________________

Student Signature Date
ACCEPTANCE OF CLINICAL HEALTH CLEARANCE
I,_________________________________, acknowledge that I have received and am responsible for understanding and complying with the policies stated in the Radiation Therapy Student Handbook. I understand that all my medical records need to be up to

date and that I am responsible for providing this information to FILE MD.
ACCEPTANCE OF RE-ENTRY CONTENT VALIDATION POLICY
I,_________________________________, acknowledge that I have received and am responsible for understanding and complying with the policies stated in the Radiation Therapy Student Handbook. I understand that I must validate previous knowledge and skills held prior to program exit before reenrollment in SON/SRS clinical professional courses. Revised 8/10





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