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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Radiation Monitoring for Pregnant Employees in Radiologic Areas
Policy Number: 12.12
Effective Date: July 1, 2016
Chapter: Safety/Emergency Management
To ensure that pregnant UW Health (UWH) radiation workers receive proper instruction concerning
prenatal radiation exposure, and that radiation levels are kept below regulatory limits and As Low As
Reasonably Achievable (ALARA) throughout the pregnancy. Any UWH staff member who is pregnant
and concerned that they are exposed to radiation may request an explanation of the radiation risks they are
exposed to and request fetal monitoring through the Pregnancy Surveillance Program.
Radiation Worker is a staff member who is trained and authorized to work with radioactive materials or
radiation producing machines.
A. A Staff member who is a radiation worker and who is pregnant should notify her supervisor
immediately to be briefed about the Pregnancy Surveillance Program. If the staff member is
interested in the Pregnancy Surveillance Program, the pregnant worker must declare her
pregnancy in writing to Radiation Safety. Management/Supervisor/Manager (See Appendix A:
Form Letter for Declaring Pregnancy). A copy of the Form Letter for Declaring Pregnancy is
submitted to UW Health Safety via email: firstname.lastname@example.org.
B. Radiation Safety will obtain the staff member’s radiation exposure history record and will meet
with the staff member to review the staff member’s radiation exposure history and current work
procedures/practices. Radiation Safety will discuss with the staff member regulatory Guide 8.13,
"Instructions Concerning Prenatal Radiation Exposure." A copy of the Regulatory Guide and
other supporting documents will be given to the staff member to read and keep for future
reference. Radiation Safety will explain the radiation exposure limits set by the Wisconsin
Department of Health Services, WI DHS 157.22 (8) for embryo/fetus due to occupational
exposure. Radiation Safety will also provide fetal dosimeter. Fetal dosimeter will be provided
unless declaration of pregnancy is withdrawn or pregnancy is completed/terminated.
C. If radiation dosimetry records show that the staff member’s annual radiation exposure levels are
within 10% of the limits set by the State of Wisconsin, appropriate action will be implemented by
her supervisor to reduce radiation exposure levels for the duration of the pregnancy.
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D. If staff member or her physician is concerned about the radiation exposure, the employee should
meet with her supervisor and Radiation Safety so that appropriate resources will be made
available to address these concerns.
E. Radiation Safety will also talk with any pregnant staff member regarding radiation exposure
Wisconsin Department of Health Services
U.S. Nuclear Regulatory Commission Regulatory Guide #8.13
Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Life Safety
Approval Committee(s): Environment of Care Safety Committee; UW Health Administrative Policy and
UW Health, Chief Administrative Officer
Previous revision: 042013
Next revision: 072019