ࡱ> SVRy Cbjbj 4J{{ LLLLL```8t L`"XjjjjEW cU!W!W!W!W!W!W!$#p&Z{!QLkEEkk{!LLjj!kRLjLjU!kU!:,)j=*R A!!0"R&&))&L kkkkkkk{!{!kkk"kkkk&kkkkkkkkk : TO BE COMPLETED BY WORKER: First Name  FORMTEXT       Middle Name  FORMTEXT       Last Name  FORMTEXT       Due Date (Year/Month/Day)  FORMTEXT       / FORMTEXT       / FORMTEXT       Telephone Number:  FORMTEXT      Department:  FORMTEXT      Radioisotope Permit Holder:  FORMTEXT      Acknowledgement: I am declaring myself to be pregnant as of the date of completion of this form. I understand the following: Occupational radiation exposure to my unborn child will not be allowed to exceed 4 mSv during the remainder of the pregnancy. Meeting the lower dose limit may require a change in job, or job responsibilities during my pregnancy but I will remain employed by the University of 鶹ý. I am responsible to forward this declaration to the Radiation Safety Officer. I am responsible to make an appointment to speak with the Radiation Safety Officer about my radiation exposure as soon as possible. I am responsible to inform my supervisor as soon as practical if I find out I am not pregnant, or if for any reason my pregnancy is terminated. Signature of Pregnant Worker: ________________________ Date: __________________________ List any and all restrictions in job duties to limit dose to the unborn child. Indicate the controls that are required. Document the assessment of potential exposure and your understanding of the specific controls. Consult with the Radiation Safety Officer if necessary. Add lines if necessary.  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       TO BE COMPLETED BY THE RADIOISOTOPE PERMIT HOLDER: I acknowledge receipt of the declaration of pregnancy by signing this statement for the above individual and have discussed the potential risks to the unborn child that could occur from radiation exposure. Name  FORMTEXT       Phone #:  FORMTEXT       Signature: ________________________ Date: __________________________  T&28NPRfhjtv㮓~mU~:~m(~m#hwwhs5CJOJQJ^JaJ4jhwwhsCJOJQJU^JaJmHnHu/jhwwhsCJOJQJU^JaJ hwwhsCJOJQJ^JaJ)jhwwhsCJOJQJU^JaJ4hwwhsCJOJPJQJ^JaJmH nH sH tH 7hwwh*a>5CJOJPJQJ^JaJmH nH sH tH 1hoo5CJOJPJQJ^JaJmH nH sH tH 7hwwhV5CJOJPJQJ^JaJmH nH sH tH :   ~u $Ifgdh qkd\$$Ifl$h% t0644 lap ytV $Ifgd3 gdt]v       & ҷҦҦ|ҷҦaH1h3 5CJOJPJQJ^JaJmH nH sH tH 4hwwh*a>CJOJPJQJ^JaJmH nH sH tH /jhwwhsCJOJQJU^JaJ#hwwhV5CJOJQJ^JaJ hwwhsCJOJQJ^JaJ4jhwwhsCJOJQJU^JaJmHnHu)jhwwhsCJOJQJU^JaJ/jthwwhsCJOJQJU^JaJ& P R T h j l v x ~ ȳoWo?o/jhwwhsCJOJQJU^JaJ/jWhwwhsCJOJQJU^JaJ4jhwwhsCJOJQJU^JaJmHnHu/jhwwhsCJOJQJU^JaJ hwwhsCJOJQJ^JaJ)jhwwhsCJOJQJU^JaJ4hwwhsCJOJPJQJ^JaJmH nH sH tH 7hwwhs5CJOJPJQJ^JaJmH nH sH tH     " $ 8 : ʱsX<7hwwhs5CJOJPJQJ^JaJmH nH sH tH 4jhwwhsCJOJQJU^JaJmHnHu/jhwwhsCJOJQJU^JaJ hwwhsCJOJQJ^JaJ)jhwwhsCJOJQJU^JaJ1h3 5CJOJPJQJ^JaJmH nH sH tH 4hwwhwwCJOJPJQJ^JaJmH nH sH tH 4hwwh*a>CJOJPJQJ^JaJmH nH sH tH  $ d vmm $Ifgd3 kd?$$Ifl0$>* t0644 lapytV: < > R T V ` b d f пЌqV:V%)jhwwhwwCJOJQJU^JaJ7hwwhww5CJOJPJQJ^JaJmH nH sH tH 4hwwhwwCJOJPJQJ^JaJmH nH sH tH 4hwwh*a>CJOJPJQJ^JaJmH nH sH tH 4jhwwhsCJOJQJU^JaJmHnHu/jRhwwhsCJOJQJU^JaJ hwwhsCJOJQJ^JaJ)jhwwhsCJOJQJU^JaJ4hwwhsCJOJPJQJ^JaJmH nH sH tH  d f vm $Ifgdh kd$$Ifl0$>* t0644 lapytV §ŒpW?#7ht]vho5CJOJPJQJ^JaJmH nH sH tH .h3 CJOJPJQJ^JaJmH nH sH tH 1ht]v5CJOJPJQJ^JaJmH nH sH tH 7hwwhV5CJOJPJQJ^JaJmH nH sH tH 4hwwhwwCJOJPJQJ^JaJmH nH sH tH 4jhwwhwwCJOJQJU^JaJmHnHu)jhwwhwwCJOJQJU^JaJ/jehwwhwwCJOJQJU^JaJ hwwhwwCJOJQJ^JaJ ` N bvddddd & Fd$IfgdV $IfgdV $Ifgdt]vm$qkd$$Ifl$h% t0644 lap yt3B _ `  ! , N a `abcͲ͚͂͂jO͚44hLbNh#hdlh15CJOJQJ^JaJh?jh?U4hwwh*a>CJOJPJQJ^JaJmH nH sH tH 4h6hCJOJPJQJ^JaJmH nH sH tH h? hVh17hdlh16CJOJPJQJ^JaJmH nH sH tH 1h16CJOJPJQJ^JaJmH nH sH tH h1#hdlh15CJOJQJ^JaJh 5CJOJQJ^JaJh15CJOJQJ^JaJ T@V@CCCCCCgdh gdV dgdj dgddl21h:pdl/ =!"#5$% tDText1tDText1tDText1$$If!vh#vh%:V l t065h%p ytVtDText1tDText1tDText1$$If!vh#v>#v*:V l t065>5*pytVtDText1tDText1$$If!vh#v>#v*:V l t065>5*pytVtDText1$$If!vh#vh%:V l t065h%p yt3BtDText1tDText1tDText1tDText1$$If!vh#vh%:V l t065h%p ytVtDText1tDText1$$If!vh#vh%:V l t065h%p ytV$$If!vh#vh%:V l t065h%p yt6j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List jj *a> Table Grid7:V04@4 V0Header  H$BoB V0 Header CharCJaJmH sH tH 4 @"4 V0Footer  H$Bo1B V0 Footer CharCJaJmH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] J LL    & : ct@C # d b?T@C "$(4:Q]cu *0O[a  +1>JP FFFFFFFFFFFFFFF8@0(  B S  ?Text1) ; 58  tu!,Naab   tu!,Naab   Y.2;ֈC^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hH;Y.@                 lf^^i@(ln(l0 ^U;i^^U+(l(lA(l6 ^|(^/9,(l[;=^^!A^$#\L(liL(lOPT(l\EZ(la^b^/d(lbtp^8cq^rir(l\(}(l<(l3 h S,6*a>3pǴ!Jٱձ?@ACDEFGHIKLMNOPQTUXRoot Entry F,WData &1Table.&WordDocument 4JSummaryInformation(BDocumentSummaryInformation8JMsoDataStore'"=*GUESE10F3==2'"=*Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q