Safety Screening Form for Magnetic Resonance (MR) Controlled Access Areas

MPORTANT INSTRUCTIONS


Before entering the MR environment or MR system room, you must remove all metallic objects including hearing aids, keys, pager, cell phone, hair pins, barrettes, fitness trackers, watch, change, wallet, scissors, hemostats, safety pins, paperclips, credit cards, debit cards, pens, pocket knife, nail clipper, tools, clothing with metal fasteners, and clothing with metallic threads.


Please consult the MR Technologist or Radiologist if have any questions or concerns BEFORE you enter the MR system room.

Name (First, Middle, Last)

Please enter your Duke Unique ID. If you do not have one, list your phone number.

WARNING

Entry into MRI may be hazardous to certain implants, devices, or objects. Do not enter the MR system room or the MR environment if you have any question or concern regarding an implant, device, or object. Consult the MR Technologist or Radiologist BEFORE entering the MR system room.


The MR system magnet is ALWAYS on.

3.*

Have you had prior surgery or operation (e.g. arthroscopy, endoscopy, etc.) of any kind?

4.*

Have you had an injury to the eye involving a metallic object or fragment (e.g., metallic slivers, shavings, foreign body, etc.)?

5.*

Have you ever been injured by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.)?

Please provide detail, if you selected yes to any of the questions above, otherwise put N/A.

Please indicate if you have any of the following: Select ALL that apply.

Please provide detail, if you selected "Any type of implant not described above" for question #7, otherwise put N/A.

Do you need badge access for entry to MRI?

Select
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10.*

(e.g., Vendor specific Field Service Engineer, Vendor, Installation team, etc.)

Select
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Select
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Provide justification for your need for badge access to the restricted zones in MRI.

List the most recent train date for the MRI Safety for Operational Staff.

https://sms.duhs.duke.edu/onlinetraining/RS104/

If completing the Intraoperative MRI training (number 14) instead, you do not have to complete this one. Use the date from number 14.

List the most recent train date for IMRI Safety for Perioperative Staff.

https://sms.duhs.duke.edu/onlinetraining/RS126/

Does not have to be completed if you are not involved in Intraoperative MRI

List the most recent train date for Ancillary Staff.


Supplemental Training Module: https://www.youtube.com/watch?v=rJXgeqOdEtc

Please provide your Duke Card Number located on the back of your badge. This is the long number in the bottom right corner for the badge that you will physically swipe for badge access to MRI.

Vendor Specific Field Service Engineer Training Requirements

Vendor specific field service engineers, please attach documentation that certifies your most recent completion of advanced level MRI safety training.

Please upload Training Module Certificate(s) here.

Drag and drop files here or

Provide your email attesting that all of the information submitted is true and correct to the best of your knowledge. You will receive confirmation of this requesting e-signature.

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