Environmental Health and Safety



Environmental Health and Safety

Confidential

Research Magnetic Resonance Imaging (MRI)

Medical Safety Screening Form

All persons MUST complete and submit this form prior to entry into MR suite or as directed.

 

Date (mm/dd/yyyy): Name: Daytime Phone:
 
Employee ID: 		 
  Department:

The MR system has a very strong magnetic field that is ON at all times.

The following conditions may put you at risk in the MRI room.  
 
 

  1.  
  2. Prior Surgery or an Operation Involving Metal Objects Examples: aneurism (clips), Cardiac pacemaker, implanted cardioverter defibrillator (ICD), cardiac (heart) stent, any other vascular stent, etc.
  3. Other Implant Devices Examples: Cochlear implant or implanted hearing aid, drug-infusion pump (including Insulin infusion pump), any other electronic implant device. Other implants: Artificial or prosthetic limb, any type of pin, nail, wire or prosthesis, etc.
  4. Neurostimulation System
  5. Spinal Cord Stimulator
  6. Any Injury to Eye that might have involved metallic slivers or foreign body.
  7. Other Bodily Injury by a metallic object or foreign body Examples: BB, bullet, shrapnel, etc.
  8. Transdermal Medication Patches
  9. Any metallic fragment or foreign body
  10. Any external or internal metallic object
  11. Pregnant or suspect that you are pregnant

 

☐ I have reviewed the above conditions and I DO NOT have any of the above conditions that may put me at risk in the MR environment. Give this form to MR Staff or fax at 206-543-3495.
☐ There has been no change since my most recent MR Clearance issued by the Employee Health Center-UW (EHC-UW).  Give this form to MR Staff or fax at 206-543-3495.
☐ I have one or more of the conditions above. Contact EHC-UW at 206-685-1026 to discuss conditions and/or to schedule an appointment. You may enter the MRI facility only after EHC-UW provides MR Clearance via a fax notification to the MR staff.
I affirm that I have had the opportunity to have my questions regarding the MRI risks addressed.
Entrant’s signature: Date:
MR staff person’s name (printed): Date:






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    Environmental Health and Safety

    Environmental Health and Safety

    Confidential

    Research Magnetic Resonance Imaging (MRI)

    Medical Safety Screening Form

    All persons MUST complete and submit this form prior to entry into MR suite or as directed.

     

    Date (mm/dd/yyyy): Name: Daytime Phone:
     
    Employee ID:     		 
      Department:

    The MR system has a very strong magnetic field that is ON at all times.

    The following conditions may put you at risk in the MRI room.  
     
     

    1.  
    2. Prior Surgery or an Operation Involving Metal Objects Examples: aneurism (clips), Cardiac pacemaker, implanted cardioverter defibrillator (ICD), cardiac (heart) stent, any other vascular stent, etc.
    3. Other Implant Devices Examples: Cochlear implant or implanted hearing aid, drug-infusion pump (including Insulin infusion pump), any other electronic implant device. Other implants: Artificial or prosthetic limb, any type of pin, nail, wire or prosthesis, etc.
    4. Neurostimulation System
    5. Spinal Cord Stimulator
    6. Any Injury to Eye that might have involved metallic slivers or foreign body.
    7. Other Bodily Injury by a metallic object or foreign body Examples: BB, bullet, shrapnel, etc.
    8. Transdermal Medication Patches
    9. Any metallic fragment or foreign body
    10. Any external or internal metallic object
    11. Pregnant or suspect that you are pregnant

     

    ☐ I have reviewed the above conditions and I DO NOT have any of the above conditions that may put me at risk in the MR environment. Give this form to MR Staff or fax at 206-543-3495.
    ☐ There has been no change since my most recent MR Clearance issued by the Employee Health Center-UW (EHC-UW).  Give this form to MR Staff or fax at 206-543-3495.
    ☐ I have one or more of the conditions above. Contact EHC-UW at 206-685-1026 to discuss conditions and/or to schedule an appointment. You may enter the MRI facility only after EHC-UW provides MR Clearance via a fax notification to the MR staff.
    I affirm that I have had the opportunity to have my questions regarding the MRI risks addressed.
    Entrant’s signature: Date:
    MR staff person’s name (printed): Date:
    << syringe pump high voltage power supply electrospun fiber coming out needles collectorSpell illness inpatient psychiatric hospital services psychiatric hospital medical health >>