Please complete the following form. Please note that your responses to this form will be used to determine whether your safety for working in the the MRI bays you specified above. This is not an assessment of your safety as a volunteer or participant undergoing an MRI scan.
Date Full Name Employee Phone MGH Badge Number
*Located on the back of your badge above the barcode
Date
* must provide value
Today M-D-Y
first name, middle initial (if applicable), last name
Employee Phone Number
* must provide value
MGH Badge Number
* must provide value
MGB Email Scanner Login ID - Leave blank if not known Please Select the Number of Imaging Groups your are Currently Apart of PIs/Imaging Group Position
MGB Email
* must provide value
Scanner Login Name (MGB Username)
Please select the number of imaging groups do you image under
1 2 3 4 5
"Imaging Group" Refers to PI or Lab Name that Imaging Sessions are Booked Under. [ex. Siemens, Kirsch, Martinos Core, etc.]
MARTINOS CORE A.KIM ABSTON ACKERMAN ADALSTEINSSON AGANJ AHLFORS AHVENINEN AKAM AKEJU AMARIGLIO ANAND ANDRONESI ARNOLD AUGUSTINACK AY AYATA BABU BADR BARRY BARTELL BATTISTELLA BECKER BENNETT BERRY BIANCIARDI BILGIC BLAZEJEWSKA BONMASSAR BREAKEFIELD BRENNER BROWN BROWNELL BRUGAROLAS CAMPRODON CARAVAN CARP CASH CASSANO CASTRO CATALANO CATANA CENTER FOR COMPARATIVE MEDICINE CHAN CHENG CHHATWAL CHIANG CHOU CHU CHUNG CIESIELSKI CLAVIJO JORDAN CLERC CLINICAL COLLINS COOLEY CROWE CUSIN DALCA DAYE DEKEL DENG DESBORDES DICKERSON DORBALA DOUGHERTY DUBACH EDLOW EDWARDS ELLARD ERYILMAZ ESFAHANI ESHGHI F. WANG FANG FARRAR FISCHL FISHER FORD FRANCESCHINI FREGNI FROST GALE GARCIA GATCHEL GEE GERSTNER GHAZNAVI GIACINO GOLDSTEIN GOLLUB GOMPERTS GOODHEART GOW GRANT GREVE GUERIN GUROL GUZMAN-VELEZ H. CHOI H. WANG HAMALAINEN HAN HEDGIRE HELMER HERRINGTON HOFFMANN HOLSEN HOLT HUANG IGLESIAS GONZALEZ ILIOPOULOS IT GROUP IZQUIERDO-GARCIA J. HOOKER J.CHEN J.THOMAS J.WANG JACOBS JCHEN JENKINS JIMENEZ JOHNSON JUTTUKONDA K. BECKER KALPATHY KARUNAKARAN KEGEL-GLEASON KENET KHAN KIMBERLEY KIMBERLY KING KIRSCH KLAWITER KOHLER KONG KUBICKI KUMAR KUO KUPERBERG KVERAGA KWON KWONG LAM LANGONE LAWSON LAZAR LE FUR LEE LEVINE LEVY LEWIS LINNMAN LIU LOGGIA LYALL M. ROSEN MA MAFFEI MAGNAIN MAGUIRE MAHMOOD MAINERO MAINTENANCE MAKRIS MANOACH MANSTEIN MARSHALL MARTIN MARTINOS MICRO MARTINOS OPTICS DIVISION MARTINOSADMIN MATEEN MCMANUS MCNALLY MEDAROVA MEG-CLINICAL MEKKAOUI MISRA MODY MONTESI MUJICA MUKERJI MUSOLINO NAHRENDORF NAPADOW NASR NATHAN NEILAN NIERENBERG NUMMENMAA NURSE HOURS O.WU OFFLINE OKI OPEN (MRI) OPEN (MRI) OPEN (PET) OSBORNE OTHER (see note) PACE-SCHOTT PARK PATEL PEREZ PETERS PEZARIS POLIMENI PRICE PUTCHA QADAN QUIROZ RAIJ RAN RATAI RICHARDSON RIELLA RIPHAGEN ROFFMAN ROHTER ROSAS ROSEN ROSENTHAL ROST S. LI SABET SACCHET SAKADZIC SALAT SAMIR SANDER SATPUTE SCHAECHTER SCHMAHMANN SCHUEMANN SCLOCCO SCHWARTZ SHARMA SHEN SHIN SIEMENS SIEMENS MAINT SIEWKO SIEWKO SIMONYAN SITNIKOVA SKOTKO SOLINSKY SOSNOVIK SPERLING STOCKMANN SVEINSSON SYSTEM DOWN TANABE TANEV TAWAKOL THERIAULT-BROWN THOM TIAN TOOTELL TOUROUTOGLOU TRAINING TZIKA UNIZONY VAINA VALERA VAN DER KOUWE VAN VELUW VANELZAKKER VANNINI VAUGHN VIDENOVIC VIJAYAKUMAR VISWANATHAN WAKIMOTO WALD WANG WEHRENGERG-KLEE WEINBERG WEY WHEELER WILHELM WILLIAMS WILLS Women in Science WOO X. KONG X.YU XIE YEN YENDIKI YU ZAFONTE ZHOU ZHU ZOLLEI ZURCHER
MARTINOS CORE A.KIM ABSTON ACKERMAN ADALSTEINSSON AGANJ AHLFORS AHVENINEN AKAM AKEJU AMARIGLIO ANAND ANDRONESI ARNOLD AUGUSTINACK AY AYATA BABU BADR BARRY BARTELL BATTISTELLA BECKER BENNETT BERRY BIANCIARDI BILGIC BLAZEJEWSKA BONMASSAR BREAKEFIELD BRENNER BROWN BROWNELL BRUGAROLAS CAMPRODON CARAVAN CARP CASH CASSANO CASTRO CATALANO CATANA CENTER FOR COMPARATIVE MEDICINE CHAN CHENG CHHATWAL CHIANG CHOU CHU CHUNG CIESIELSKI CLAVIJO JORDAN CLERC CLINICAL COLLINS COOLEY CROWE CUSIN DALCA DAYE DEKEL DENG DESBORDES DICKERSON DORBALA DOUGHERTY DUBACH EDLOW EDWARDS ELLARD ERYILMAZ ESFAHANI ESHGHI F. WANG FANG FARRAR FISCHL FISHER FORD FRANCESCHINI FREGNI FROST GALE GARCIA GATCHEL GEE GERSTNER GHAZNAVI GIACINO GOLDSTEIN GOLLUB GOMPERTS GOODHEART GOW GRANT GREVE GUERIN GUROL GUZMAN-VELEZ H. CHOI H. WANG HAMALAINEN HAN HEDGIRE HELMER HERRINGTON HOFFMANN HOLSEN HOLT HUANG IGLESIAS GONZALEZ ILIOPOULOS IT GROUP IZQUIERDO-GARCIA J. HOOKER J.CHEN J.THOMAS J.WANG JACOBS JCHEN JENKINS JIMENEZ JOHNSON JUTTUKONDA K. BECKER KALPATHY KARUNAKARAN KEGEL-GLEASON KENET KHAN KIMBERLEY KIMBERLY KING KIRSCH KLAWITER KOHLER KONG KUBICKI KUMAR KUO KUPERBERG KVERAGA KWON KWONG LAM LANGONE LAWSON LAZAR LE FUR LEE LEVINE LEVY LEWIS LINNMAN LIU LOGGIA LYALL M. ROSEN MA MAFFEI MAGNAIN MAGUIRE MAHMOOD MAINERO MAINTENANCE MAKRIS MANOACH MANSTEIN MARSHALL MARTIN MARTINOS MICRO MARTINOS OPTICS DIVISION MARTINOSADMIN MATEEN MCMANUS MCNALLY MEDAROVA MEG-CLINICAL MEKKAOUI MISRA MODY MONTESI MUJICA MUKERJI MUSOLINO NAHRENDORF NAPADOW NASR NATHAN NEILAN NIERENBERG NUMMENMAA NURSE HOURS O.WU OFFLINE OKI OPEN (MRI) OPEN (MRI) OPEN (PET) OSBORNE OTHER (see note) PACE-SCHOTT PARK PATEL PEREZ PETERS PEZARIS POLIMENI PRICE PUTCHA QADAN QUIROZ RAIJ RAN RATAI RICHARDSON RIELLA RIPHAGEN ROFFMAN ROHTER ROSAS ROSEN ROSENTHAL ROST S. LI SABET SACCHET SAKADZIC SALAT SAMIR SANDER SATPUTE SCHAECHTER SCHMAHMANN SCHUEMANN SCLOCCO SCWARTZ SHARMA SHEN SHIN SIEMENS SIEMENS MAINT SIEWKO SIEWKO SIMONYAN SITNIKOVA SKOTKO SOLINSKY SOSNOVIK SPERLING STOCKMANN SVEINSSON SYSTEM DOWN TANABE TANEV TAWAKOL THERIAULT-BROWN THOM TIAN TOOTELL TOUROUTOGLOU TRAINING TZIKA UNIZONY VAINA VALERA VAN DER KOUWE VAN VELUW VANELZAKKER VANNINI VAUGHN VIDENOVIC VIJAYAKUMAR VISWANATHAN WAKIMOTO WALD WANG WEHRENGERG-KLEE WEINBERG WEY WHEELER WILHELM WILLIAMS WILLS Women in Science WOO X. KONG X.YU XIE YEN YENDIKI YU ZAFONTE ZHOU ZHU ZOLLEI ZURCHER
MARTINOS CORE A.KIM ABSTON ACKERMAN ADALSTEINSSON AGANJ AHLFORS AHVENINEN AKAM AKEJU AMARIGLIO ANAND ANDRONESI ARNOLD AUGUSTINACK AY AYATA BABU BADR BARRY BARTELL BATTISTELLA BECKER BENNETT BERRY BIANCIARDI BILGIC BLAZEJEWSKA BONMASSAR BREAKEFIELD BRENNER BROWN BROWNELL BRUGAROLAS CAMPRODON CARAVAN CARP CASH CASSANO CASTRO CATALANO CATANA CENTER FOR COMPARATIVE MEDICINE CHAN CHENG CHHATWAL CHIANG CHOU CHU CHUNG CIESIELSKI CLAVIJO JORDAN CLERC CLINICAL COLLINS COOLEY CROWE CUSIN DALCA DAYE DEKEL DENG DESBORDES DICKERSON DORBALA DOUGHERTY DUBACH EDLOW EDWARDS ELLARD ERYILMAZ ESFAHANI ESHGHI F. WANG FANG FARRAR FISCHL FISHER FORD FRANCESCHINI FREGNI FROST GALE GARCIA GATCHEL GEE GERSTNER GHAZNAVI GIACINO GOLDSTEIN GOLLUB GOMPERTS GOODHEART GOW GRANT GREVE GUERIN GUROL GUZMAN-VELEZ H. CHOI H. WANG HAMALAINEN HAN HEDGIRE HELMER HERRINGTON HOFFMANN HOLSEN HOLT HUANG IGLESIAS GONZALEZ ILIOPOULOS IT GROUP IZQUIERDO-GARCIA J. HOOKER J.CHEN J.THOMAS J.WANG JACOBS JCHEN JENKINS JIMENEZ JOHNSON JUTTUKONDA K. BECKER KALPATHY KARUNAKARAN KEGEL-GLEASON KENET KHAN KIMBERLEY KIMBERLY KING KIRSCH KLAWITER KOHLER KONG KUBICKI KUMAR KUO KUPERBERG KVERAGA KWON KWONG LAM LANGONE LAWSON LAZAR LE FUR LEE LEVINE LEVY LEWIS LINNMAN LIU LOGGIA LYALL M. ROSEN MA MAFFEI MAGNAIN MAGUIRE MAHMOOD MAINERO MAINTENANCE MAKRIS MANOACH MANSTEIN MARSHALL MARTIN MARTINOS MICRO MARTINOS OPTICS DIVISION MARTINOSADMIN MATEEN MCMANUS MCNALLY MEDAROVA MEG-CLINICAL MEKKAOUI MISRA MODY MONTESI MUJICA MUKERJI MUSOLINO NAHRENDORF NAPADOW NASR NATHAN NEILAN NIERENBERG NUMMENMAA NURSE HOURS O.WU OFFLINE OKI OPEN (MRI) OPEN (MRI) OPEN (PET) OSBORNE OTHER (see note) PACE-SCHOTT PARK PATEL PEREZ PETERS PEZARIS POLIMENI PRICE PUTCHA QADAN QUIROZ RAIJ RAN RATAI RICHARDSON RIELLA RIPHAGEN ROFFMAN ROHTER ROSAS ROSEN ROSENTHAL ROST S. LI SABET SACCHET SAKADZIC SALAT SAMIR SANDER SATPUTE SCHAECHTER SCHMAHMANN SCHUEMANN SCLOCCO SCWARTZ SHARMA SHEN SHIN SIEMENS SIEMENS MAINT SIEWKO SIEWKO SIMONYAN SITNIKOVA SKOTKO SOLINSKY SOSNOVIK SPERLING STOCKMANN SVEINSSON SYSTEM DOWN TANABE TANEV TAWAKOL THERIAULT-BROWN THOM TIAN TOOTELL TOUROUTOGLOU TRAINING TZIKA UNIZONY VAINA VALERA VAN DER KOUWE VAN VELUW VANELZAKKER VANNINI VAUGHN VIDENOVIC VIJAYAKUMAR VISWANATHAN WAKIMOTO WALD WANG WEHRENGERG-KLEE WEINBERG WEY WHEELER WILHELM WILLIAMS WILLS Women in Science WOO X. KONG X.YU XIE YEN YENDIKI YU ZAFONTE ZHOU ZHU ZOLLEI ZURCHER
MARTINOS CORE A.KIM ABSTON ACKERMAN ADALSTEINSSON AGANJ AHLFORS AHVENINEN AKAM AKEJU AMARIGLIO ANAND ANDRONESI ARNOLD AUGUSTINACK AY AYATA BABU BADR BARRY BARTELL BATTISTELLA BECKER BENNETT BERRY BIANCIARDI BILGIC BLAZEJEWSKA BONMASSAR BREAKEFIELD BRENNER BROWN BROWNELL BRUGAROLAS CAMPRODON CARAVAN CARP CASH CASSANO CASTRO CATALANO CATANA CENTER FOR COMPARATIVE MEDICINE CHAN CHENG CHHATWAL CHIANG CHOU CHU CHUNG CIESIELSKI CLAVIJO JORDAN CLERC CLINICAL COLLINS COOLEY CROWE CUSIN DALCA DAYE DEKEL DENG DESBORDES DICKERSON DORBALA DOUGHERTY DUBACH EDLOW EDWARDS ELLARD ERYILMAZ ESFAHANI ESHGHI F. WANG FANG FARRAR FISCHL FISHER FORD FRANCESCHINI FREGNI FROST GALE GARCIA GATCHEL GEE GERSTNER GHAZNAVI GIACINO GOLDSTEIN GOLLUB GOMPERTS GOODHEART GOW GRANT GREVE GUERIN GUROL GUZMAN-VELEZ H. CHOI H. WANG HAMALAINEN HAN HEDGIRE HELMER HERRINGTON HOFFMANN HOLSEN HOLT HUANG IGLESIAS GONZALEZ ILIOPOULOS IT GROUP IZQUIERDO-GARCIA J. HOOKER J.CHEN J.THOMAS J.WANG JACOBS JCHEN JENKINS JIMENEZ JOHNSON JUTTUKONDA K. BECKER KALPATHY KARUNAKARAN KEGEL-GLEASON KENET KHAN KIMBERLEY KIMBERLY KING KIRSCH KLAWITER KOHLER KONG KUBICKI KUMAR KUO KUPERBERG KVERAGA KWON KWONG LAM LANGONE LAWSON LAZAR LE FUR LEE LEVINE LEVY LEWIS LINNMAN LIU LOGGIA LYALL M. ROSEN MA MAFFEI MAGNAIN MAGUIRE MAHMOOD MAINERO MAINTENANCE MAKRIS MANOACH MANSTEIN MARSHALL MARTIN MARTINOS MICRO MARTINOS OPTICS DIVISION MARTINOSADMIN MATEEN MCMANUS MCNALLY MEDAROVA MEG-CLINICAL MEKKAOUI MISRA MODY MONTESI MUJICA MUKERJI MUSOLINO NAHRENDORF NAPADOW NASR NATHAN NEILAN NIERENBERG NUMMENMAA NURSE HOURS O.WU OFFLINE OKI OPEN (MRI) OPEN (MRI) OPEN (PET) OSBORNE OTHER (see note) PACE-SCHOTT PARK PATEL PEREZ PETERS PEZARIS POLIMENI PRICE PUTCHA QADAN QUIROZ RAIJ RAN RATAI RICHARDSON RIELLA RIPHAGEN ROFFMAN ROHTER ROSAS ROSEN ROSENTHAL ROST S. LI SABET SACCHET SAKADZIC SALAT SAMIR SANDER SATPUTE SCHAECHTER SCHMAHMANN SCHUEMANN SCLOCCO SCWARTZ SHARMA SHEN SHIN SIEMENS SIEMENS MAINT SIEWKO SIEWKO SIMONYAN SITNIKOVA SKOTKO SOLINSKY SOSNOVIK SPERLING STOCKMANN SVEINSSON SYSTEM DOWN TANABE TANEV TAWAKOL THERIAULT-BROWN THOM TIAN TOOTELL TOUROUTOGLOU TRAINING TZIKA UNIZONY VAINA VALERA VAN DER KOUWE VAN VELUW VANELZAKKER VANNINI VAUGHN VIDENOVIC VIJAYAKUMAR VISWANATHAN WAKIMOTO WALD WANG WEHRENGERG-KLEE WEINBERG WEY WHEELER WILHELM WILLIAMS WILLS Women in Science WOO X. KONG X.YU XIE YEN YENDIKI YU ZAFONTE ZHOU ZHU ZOLLEI ZURCHER
MARTINOS CORE A.KIM ABSTON ACKERMAN ADALSTEINSSON AGANJ AHLFORS AHVENINEN AKAM AKEJU AMARIGLIO ANAND ANDRONESI ARNOLD AUGUSTINACK AY AYATA BABU BADR BARRY BARTELL BATTISTELLA BECKER BENNETT BERRY BIANCIARDI BILGIC BLAZEJEWSKA BONMASSAR BREAKEFIELD BRENNER BROWN BROWNELL BRUGAROLAS CAMPRODON CARAVAN CARP CASH CASSANO CASTRO CATALANO CATANA CENTER FOR COMPARATIVE MEDICINE CHAN CHENG CHHATWAL CHIANG CHOU CHU CHUNG CIESIELSKI CLAVIJO JORDAN CLERC CLINICAL COLLINS COOLEY CROWE CUSIN DALCA DAYE DEKEL DENG DESBORDES DICKERSON DORBALA DOUGHERTY DUBACH EDLOW EDWARDS ELLARD ERYILMAZ ESFAHANI ESHGHI F. WANG FANG FARRAR FISCHL FISHER FORD FRANCESCHINI FREGNI FROST GALE GARCIA GATCHEL GEE GERSTNER GHAZNAVI GIACINO GOLDSTEIN GOLLUB GOMPERTS GOODHEART GOW GRANT GREVE GUERIN GUROL GUZMAN-VELEZ H. CHOI H. WANG HAMALAINEN HAN HEDGIRE HELMER HERRINGTON HOFFMANN HOLSEN HOLT HUANG IGLESIAS GONZALEZ ILIOPOULOS IT GROUP IZQUIERDO-GARCIA J. HOOKER J.CHEN J.THOMAS J.WANG JACOBS JCHEN JENKINS JIMENEZ JOHNSON JUTTUKONDA K. BECKER KALPATHY KARUNAKARAN KEGEL-GLEASON KENET KHAN KIMBERLEY KIMBERLY KING KIRSCH KLAWITER KOHLER KONG KUBICKI KUMAR KUO KUPERBERG KVERAGA KWON KWONG LAM LANGONE LAWSON LAZAR LE FUR LEE LEVINE LEVY LEWIS LINNMAN LIU LOGGIA LYALL M. ROSEN MA MAFFEI MAGNAIN MAGUIRE MAHMOOD MAINERO MAINTENANCE MAKRIS MANOACH MANSTEIN MARSHALL MARTIN MARTINOS MICRO MARTINOS OPTICS DIVISION MARTINOSADMIN MATEEN MCMANUS MCNALLY MEDAROVA MEG-CLINICAL MEKKAOUI MISRA MODY MONTESI MUJICA MUKERJI MUSOLINO NAHRENDORF NAPADOW NASR NATHAN NEILAN NIERENBERG NUMMENMAA NURSE HOURS O.WU OFFLINE OKI OPEN (MRI) OPEN (MRI) OPEN (PET) OSBORNE OTHER (see note) PACE-SCHOTT PARK PATEL PEREZ PETERS PEZARIS POLIMENI PRICE PUTCHA QADAN QUIROZ RAIJ RAN RATAI RICHARDSON RIELLA RIPHAGEN ROFFMAN ROHTER ROSAS ROSEN ROSENTHAL ROST S. LI SABET SACCHET SAKADZIC SALAT SAMIR SANDER SATPUTE SCHAECHTER SCHMAHMANN SCHUEMANN SCLOCCO SCWARTZ SHARMA SHEN SHIN SIEMENS SIEMENS MAINT SIEWKO SIEWKO SIMONYAN SITNIKOVA SKOTKO SOLINSKY SOSNOVIK SPERLING STOCKMANN SVEINSSON SYSTEM DOWN TANABE TANEV TAWAKOL THERIAULT-BROWN THOM TIAN TOOTELL TOUROUTOGLOU TRAINING TZIKA UNIZONY VAINA VALERA VAN DER KOUWE VAN VELUW VANELZAKKER VANNINI VAUGHN VIDENOVIC VIJAYAKUMAR VISWANATHAN WAKIMOTO WALD WANG WEHRENGERG-KLEE WEINBERG WEY WHEELER WILHELM WILLIAMS WILLS Women in Science WOO X. KONG X.YU XIE YEN YENDIKI YU ZAFONTE ZHOU ZHU ZOLLEI ZURCHER
Affiliated Faculty CCM Employee CTRU Employee Radiopharmacy Staff Research Staff Martinos Faculty MRI Technologist NM Technologist Vendor Visitor/Other
Please Specify Position/Role
Please Select Which Scanners/Bays You Will Need Access To
*Please be mindful when making selections as this will determine your badge access. If you are unsure please contact a member of your direct study team (PI, Lab manager) to clarify before submitting this form.
Please Select the Sample Population Current Badge Status
Please Select Which Scanners/Bays you will need badge access toYour badge access will be determined by your selections on this question
* must provide value
Working with
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Imaging Badge Status
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WARNING
Certain implants, devices or objects may be hazardous to you and/or may interfere with the MRI procedure. Do Not Enter the MRI scan room or MRI environment if you have any questions or concerns regarding an implant, device, or object. Always consult the center MRI technologists BEFORE entering the MRI scan room.
You must remove all metallic objects including, but not limited to: hearing aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hairpins, barrettes, jewelry, body piercings, watch, safety pins, paperclips, money clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, and wearable elecronics or devices BEFORE entering the MRI environment.
Please consult with MRI Technologists if you have any questions or concerns
Pacemaker, pacing wires, or ICD (Implantable Cardioverter Defibrillator)
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Brain Aneurysm Clip(s) or Other Intercranial Hardware
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Cochlear Implant, otologic or other ear implant/surgery
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
Yes No Unsure
Any type of stimulator (neuro, spinal cord, bone growth, bone fusion, etc.)
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Injury with or removal of metallic object/fragment from the eyes or other part of the body (e.g. BB, bullet, shrapnel, metallic shavings, foreign body, etc.)
* must provide value
Yes
No
Please describe the injury, including type of object, location in the body, and if any removal procedures or medical imaging were performed.
Shunt (spinal or Intraventricular)
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
Yes No Unsure
Internal electrodes or wires
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Heart Valve Prosthesis
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Stent, filter, aneurysm coil, clip or graft
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Vascular Access port and/or catheter
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Electronic and/or magnetically activated implant or device
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
Yes No Unsure
Implanted insulin or other drug infusion device or pump
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Bone or joint pin, replacement, screw, nail, wire, plate, rod, etc.
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
Yes No Unsure
Any type of prosthesis (artificial limb, penile, eye, etc.)
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain electronic component(s)?
Yes No Unsure
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Surgical staples, clips, wire mesh or metallic sutures
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Radiation seeds or implants
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Eyelid spring, wire, or weight
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Tissue expander (e.g. breast)
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain electronic component(s)?
Yes No Unsure
Dentures, partial plates, dental implant
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
Yes No Unsure
Orthodontic hardware (e.g. braces, palate expander, wires, etc.)
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information.
*If your orthodontic hardware is loose, or not secured in place properly, please also note that here
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
Yes No Unsure
Medication patch (nicotine, nitroglycerin, pain, HRT, etc.)
* must provide value
Yes
No
Remove before entering MRI scan room
Hair wig, extensions, or head covering
* must provide value
Yes
No
Remove before entering MRI scan room
Metallic or magnetic cosmetics (e.g. nail polish, make-up, cosmetic contacts, etc.)
* must provide value
Yes
No
Remove before entering MRI scan room
Body Piercing Jewelry (e.g. earrings, dermal piercings, etc.)
* must provide value
Yes
No
Remove all piercings before entering MRI scan room
Hearing Aid
* must provide value
Yes
No
Remove before entering MRI scan room
Tattoo or Permanent Makeup
* must provide value
Yes
No
Please describe the type of tattoo, location on the body, and when it was done, or last retouched.
Breast Implants
* must provide value
Yes
No
N/A
IUD, diaphragm, pessary or other contraceptive device
* must provide value
Yes
No
N/A
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Are you pregnant or is there any chance that you could be pregnant?
* must provide value
Yes
No
N/A
Other Implant
* must provide value
Yes
No
Please include brand name, model number(s), location in the body, quantity, and any other related information*.
*You may be asked to provide a surgical operative report or prior medical imaging report.
Does this device/implant contain magnetic component(s)?
Yes No Unsure
Does this device/implant contain electronic component(s)?
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Have you had any prior surgery or an operation (e.g. arthroscopy, endoscopy, etc.) of any kind?
* must provide value
Yes
No
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Surgery 1 Relevant Surgical Documentation
Surgery 2 Relevant Surgical Documentation
Surgery 3 Relevant Surgical Documentation
Surgery 4 Relevant Surgical Documentation
Surgery 5 Relevant Surgical Documentation
Surgery 6 Relevant Surgical Documentation
Surgery 7 Relevant Surgical Documentation
Surgery 8 Relevant Surgical Documentation
Surgery 9 Relevant Surgical Documentation
Surgery 10 {type_of_surgery_10} {date_of_surgery_10} Relevant Surgical Documentation
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Please Upload Any Additional Relevant Documentation
*You may be required to provide medical records for implant verification during screening
By signing below, I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form, and regarding working in the MRI environment.
signature attachment: ______
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Additional Safety Provisions/Notes
Send to Study Staff Approval Need More Information Not Approved Approved Work Areas Notes Notes
Grae Arabasz (Imaging Operations Manager) Jacob Calkins (MRI Technologist) Alexander Robertson (MRI Technologist) Lynelle Ferreira (MRI Technologist) Dr. Steven Stufflebeam (Medical Director) Dr. Susie Huang (Medical Safety Committee)
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Send Study Staff Approval Confirmation
By checking this field, Martinos Center Staff Member will receive an approval confirmation email
Send Study Staff: Need More Information
By checking this field, Martinos Center Staff Member will receive an email requesting more information
Send Study Staff: Not Approved
By checking this field, Martinos Center Staff Member will receive a "not approved" email
Additional Safety Provisions/Notes
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