1
Name:
Date:
Student:
Instructor:
MRI Safety Acknowledgement Statements and MRI Form 2015
Page 1: Circle your response to each Acknowledgement statement.
Page 2: Circle your response to each MRI Question and sign and date as directed below.
Return this form to your school instructor.
1. I have read the MRI Safety Education 2015 (cbl).
Yes
2. I understand that I am responsible for the information contained in the cbl.
Yes
3. I understand that the MRI magnet is always on.
Yes
4. I understand that there are four (4) safety zones in MRI.
Yes
5. I understand that some people should never come in close contact with the MRI unit, Zone 4.
Yes
6. I understand that there are many common items that should never be brought into Zones 3 & 4 and are
designated as MRI safety hazards (i.e. credit cards, keys, metal mop buckets, patient charts, pens,
scissors, standard IV pumps, stethoscopes, tools).
Yes
7. I understand that there is specialized MRI-safe equipment available (i.e. MRI-safe stretchers, oxygen
tanks, wheelchairs, fire extinguishers, IV pumps, laundry hampers).
Yes
8. I understand that my responsibilities are: to be aware of signs, to report unsafe practices or ask
questions, do not bring un-approved items into MRI, notify Occupational Health of any ferrous metals
(metals containing iron) in my body (state on the “Annual Health Screening” form).
9. I know where and how to get my questions answered.
Rev. 2/2014
Yes
Yes
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CLINICAL SHADOWING EXPERIENCE
Magnetic Resonance Imaging (MRI) Form
All MRI suites maintain a safe environment by: restricting access to all MRI work areas; requiring modified GMC identification
badges for associates who may not safely enter the MRI area; and screening “all” associates, patients, family members, and affiliates
(i.e. students and faculty) prior to entering the MRI suite for pacemakers, aneurysm clips, permanent tattoos, body piercing, hemostats,
pagers, and more. Students or faculty who have experiences in the MRI area need to be thoroughly screened and cleared to enter the
area using the MRI Safety questions below. Please circle your answers and then sign this form below.
MRI Safety Questions
1. Have you ever been hit in the face with a piece of metal (including metal shavings, slivers, rust, BB’s or bullets)?
YES
NO
2. Have you ever worked as a machinist or welder?
YES
NO
3. Have you ever had metal removed from your eye?
YES
NO
4. Do you have any metal in your body from an accident (including pencil points, shrapnel)?
YES
NO
5. Have you ever had eye surgery (other than LASIK surgery)?
YES
NO
6. Do you have any surgically implanted metal (including an intrauterine device, catheters, tubes, stints, or valves)?
YES
NO
7. Do you have or have you ever had a pacemaker, pacemaker wires, defibrillator or cardiac valve prosthesis?
YES
NO
8. Do you have a brain/aneurysm clip?
YES
NO
9. Do you have an eye/ear implant or hearing aid?
YES
NO
10. Do you have an electrical stimulator for nerves or bones?
YES
NO
My signature below validates I have answered the above questions candidly, and if I have answered “Yes” to any of the above
questions, I agree to notify MRI staff prior to entering any MRI Suite at GMC for my personal safety.
_____________________
Date
Rev. 2/2014
___________________________________________________
Signature