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Imaging Tech MR Screening Form

Below is a step-by-step process guide on how you can use the MR Screening Form! Additionally, you can watch our video tutorial by following this link: https://youtu.be/4uYK9DB5mVU

If you are going to be accessing Zone III or Zone IV, you are required for your safety to complete the MR Screening form annually. This form exists conveniently on your [CAMPUSNAME] Campus, and you can access it by using the following instructions:

  • You will need to have a [CAMPUSNAME] Campus account to complete the form. If you have not yet set one up, please access the [CAMPUSNAME] Campus User Registration Instructions. If you need a copy of the User Registration Instructions, please reach out to your supervisor.
  • Make sure you are logged in to your account and go to the screening form on your campus. The screening form exists conveniently on your campus at the following link:
    • [SITE-URL].com/mr-screening-form/
  • Answer each question. Once finished, click the blue Save Formbutton at the bottom of the screen to save your answers.
  • After saving, scroll to the bottom of the screen, type your name into the signature field, and click the button that reads, Save Form and Sign.” 
  • That’s it! Now your administrator will be able to see your form and approve it. Your signature will remain in effect for one year. Then you will need to re-verify the information. In 11 months, you will receive an email reminding you to verify the answers you have given and sign the form again.

If you have any questions or concerns as you complete the form, please reach out to client.support@altuscampus.com and we will be happy to help!

Excerpt from the American College of Radiology (ACR) Manual on MR Safety:

MR Screening

All Non-MR Personnel needing to enter Zone III must first pass an MR safety screening process. Before Non-MR Personnel enter Zone III, final authorization must originate from Level 2 MR Personnel.

Nonemergent patients should be MR safety screened at least twice prior to being granted access to the MR environment. At least 1 of these screens should be performed by Level 2 MR Personnel verbally and/or interactively. For example, the patient (or their health care proxy) may complete a screening form and subsequently have the responses and contents of that form reviewed together with a Level 2 MR Technologist.

Emergent patients and their accompanying Non-MR Personnel may be screened only once, provided that the screening individual has Level 2 MR Personnel status. Any exceptions to this (such as but not limited to cases where a screening induced delay may result in imminent patient paralysis, blindness, and/or death) must be with the mutual agreement of the ordering physician and covering Level 2 MR Physician, who specifically acknowledge the potential risks of a decision NOT to screen prior to granting that patient MR access.

The screening process and forms for patients, Non-MR Personnel, and MR Personnel should be essentially identical. Specifically, one should assume that screened Non-MR Personnel, health care practitioners, or MR Personnel might enter the bore of the MR system and be exposed to the static and/or time-varying magnetic fields at any time.

Examples of this include if a pediatric patient cries for his mother, who then leans into the bore of the scanner, or if an anesthesiologist leans into the bore to manually ventilate a patient in the event of a problem.

Careful screening for ferromagnetic materials by direct inspection and use of a ferromagnetic detector is recommended prior to entering Zone IV. MR Conditional devices may be ferrous, which can lead to activation of ferromagnetic detectors prior to entry into Zone IV. The manufacturers of ferromagnetic detectors today do not claim utility or sensitivity for screening of implants or foreign bodies within patients, although if sufficiently large and/or superficial, implant detection may be possible.

Staff/Personnel Screening

All MR Personnel are to undergo an MR screening process as part of their employment agreement to ensure their safety in the MR environment. For their own protection and for the protection of the Non-MR Personnel under their supervision, all MR Personnel must immediately report to the MRMD any trauma, procedure, or surgery they experience or undergo where a ferromagnetic object or device may have become introduced within or on them. This will permit appropriate screening of the employee to determine the safety of permitting that employee into Zones III and/or IV.