UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
IMAGING POLICY AND PROCEDURE
Radiation Monitoring for pregnant Employees in Radiologic areas
Effective Date: September 1 2013 Approval: See Authorization
Supersedes Protocol: None Contact:
PURPOSE: To insure that pregnant University of Wisconsin Medical Foundation
(UWMF) 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 UWMF employee
who is pregnant and concerned that they are exposed to radiation may request an
explanation of the radiation risks they are exposed to and receive fetal monitoring
through the Pregnancy Surveillance Program.
A. An employee who is a radiation worker and who is pregnant should notify her
supervisor immediately to be briefed about the Pregnancy Surveillance Program
at UWMF. If worker is interested in the Pregnancy Surveillance Program, the
pregnant worker must declare her pregnancy in writing to UWMF.
Management/Supervisor/Manager (See Appendix A: Form Letter for Declaring
Pregnancy). A copy of the Form Letter for Declaring Pregnancy is submitted to
the UWHC Health Physicist (UWHC HP) who will send a copy to the UW
Radiation Safety Officer (RSO).
B. The RSO/UWMF HP will obtain the employee's radiation exposure history record
and will meet with the employee to review the employee's radiation exposure
history and current work procedures/practices. The RSO/UWMF HP will discuss
with the employee regulatory Guide 8.13, "Instructions Concerning Prenatal
Radiation Exposure." A copy of the Regulatory Guide will be given to the
employee to read and keep for future reference. The RSO/UWMF HP will explain
the radiation exposure limits set by the Wisconsin Department of Health Services,
WI DHS 157 for embryo/fetus due to occupational exposure. The RSO/UWMF
HP will also provide fetal dosimeter. Fetal dosimeter will be provided unless
declaration of pregnancy is withdrawn or pregnancy is completed /terminated.
C. If radiation dosimeter records show that the employee'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.
D. If employee or her physician is concerned about the radiation exposure, the
employee should meet with her supervisor and UWMF HP so that appropriate
resources will be made available to address these concerns.
E. The RSO/UWMF HP will also talk with pregnant, non-radiation workers (or any
worker) regarding radiation exposure concerns.
Kari Pulfer, R.T. (R)(CT) BS, Medical Imaging Manager
Lynn Broderick, MD Modality Chief Radiologist – Radiology, University of Wisconsin
Peter Chase, MD Modality Chief Radiologist – Radiology, University of Wisconsin
Samuel Charles, MD Medical Director Radiologist – Radiology, University of Wisconsin
Department of Radiology Community Section
John Vetter PhD ASSOC PROFESSOR (CHS) (UWSMPH) Medical Physicist, University of
AUTHORIZATION: Richard Welnick, MD, Medical Director, UWMF
Wisconsin Department of Health Services DHS 157
U.S. Nuclear Regulatory Commission Regulatory Guide #8.13
Medical Director Date