Page 85 - Radiography Flipbook

Magnetic Resonance Screening Form for Students

Magnetic resonance (MR) is a medical imaging system in the radiology department that uses a magnetic field and radio waves.
This magnetic field could potentially be hazardous to students entering the environment if they have specific metallic,
electronic, magnetic, and/or mechanical devices. Because of this, students must be screened to identify any potential hazards
of entering the magnetic resonance environment before beginning clinical rotations.

Pregnancy Notice: The declared pregnant student who continues to work in and around the MR environment should not
remain within the MR scanner room or Zone IV during actual data acquisition or scanning.
Name: _______________________________________ Date: ________________

Circle Yes or No
1. Have you had prior surgery or an operation of any kind? Yes No
If yes to question 1, please indicate the date and type of surgery:
Date: __________ Surgery Type: ________________________
2. Have you had an injury to the eye involving a metallic object (e.g. Yes No
metallic slivers, foreign body)?
If yes to question 2, please describe: _______________________________
_____________________________________________________________
3. Have you ever been injured by a metallic object or foreign body (e.g., Yes No
BB, bullet, shrapnel, etc.)?
If yes to question 3, please describe: ________________________________
______________________________________________________________
Please indicate if you have any of the following:
Aneurysm clip(s) Yes No
Cardiac pacemaker Yes No
Implanted cardioverter defibrillator (ICD) Yes No
Electronic implant or device Yes No
Magnetically-activated implant or device Yes No
Neurostimulator system Yes No
Spinal cord stimulator Yes No
Cochlear implant or implanted hearing aid Yes No
Insulin or infusion pump Yes No
Implanted drug infusion device Yes No
Any type of prosthesis or implant Yes No
Artificial or prosthetic limb Yes No
Any metallic fragment or foreign body Yes No
Any external or internal metallic object Yes No
Hearing aid Yes No
Other device: _______________ Yes No
I attest that the above information is correct to the best of my knowledge. I have read and understand the entire
contents of this form and have had the opportunity to ask questions regarding the information on this form. Should any
of this information change, I will inform my program director.

Signature of Person Completing Form: _____________________________________Date _____/_____/_____

The student has not identified any contraindications to entering MR Zone III or IV.
The student has identified contraindications to entering MR Zones III and IV. The student has been advised not to progress past MR
Zone II unless screened by an MR Level II Technologist onsite at each clinical setting.
Form Information Reviewed By: _____________________ _____________________ __________________ ____________
Print name Signature Title Student Initials

This form is provided by the JRCERT as a resource for programs. Programs are encouraged to personalize the form prior to use.
Remember: The magnet is always on!