Run MRI Zone IV Safety Screen — Free

Screening Context and Identity

Person being screened identified and role confirmed critical (required)

Record the name or identifier and whether the person is a patient, visitor, or staff member.

MRI Zone IV access requested for this entry critical (required)

Confirm this screening is being completed immediately before Zone IV access.

Yes No N/A

Screening completed by authorized MRI personnel critical (required)

Confirm the screener is trained and authorized per facility MRI safety policy.

Yes No N/A

Current MRI safety screening form or protocol used

Enter the form name, version, or protocol reference used for this screening.

Any uncertainty escalated to MRI safety officer or radiologist critical (required)

Use when implant, device, or history details are unclear or incomplete.

Yes No N/A

Implants, Devices, and Conditional Equipment

Presence of ferromagnetic implants or foreign bodies screened critical (required)

Confirm screening for aneurysm clips, shrapnel, bullets, metallic foreign bodies, cochlear implants, neurostimulators, and other ferromagnetic implants.

Yes No N/A

MRI-conditional implant/device status verified against conditions of use critical (required)

Verify any MRI-conditional implant or device is permitted only within the exact manufacturer conditions, including field strength, SAR, positioning, and monitoring requirements.

Yes No N/A

Implant or device make/model and MRI conditions documented critical (required)

Record the device name, manufacturer, model, and any applicable MRI conditions or restrictions.

External or removable medical devices removed or approved for Zone IV critical (required)

Confirm items such as insulin pumps, infusion pumps, transdermal patches with metal, hearing aids, prostheses, wheelchairs, walkers, and monitoring devices are removed or specifically cleared for MRI entry.

Yes No N/A

Battery-powered or electronically controlled device screened for MRI compatibility critical (required)

Confirm any battery-powered or electronically controlled device has been checked for MRI safety status before entry.

Yes No N/A

Personal Items, Clothing, and External Aids

All metallic personal items removed critical (required)

Confirm removal of keys, coins, phones, jewelry, watches, credit cards, pens, hairpins, piercings, and other metallic objects.

Yes No N/A

Clothing screened for metal fasteners, wires, or conductive materials critical (required)

Verify clothing is MRI-safe and free of zippers, snaps, underwire, metallic threads, or other conductive components.

Yes No N/A

External aids removed or approved critical (required)

Confirm removal or MRI clearance of glasses, dentures, wigs, hearing aids, orthotics, braces, and similar external aids.

Yes No N/A

Wheelchair, stretcher, or mobility aid checked for MRI compatibility critical (required)

Verify any mobility aid entering Zone IV is MRI-safe or MRI-conditional and free of unsecured ferromagnetic components.

Yes No N/A

Monitoring, Pumps, and Life Support Equipment

Infusion pumps, syringe pumps, and IV poles screened before entry critical (required)

Confirm pumps and poles are MRI-safe/conditional or removed from Zone IV as required by facility policy.

Yes No N/A

Monitoring equipment screened for MRI compatibility critical (required)

Verify pulse oximeters, ECG leads, blood pressure equipment, and other monitors are MRI-safe or MRI-conditional for the planned scan.

Yes No N/A

Oxygen cylinders, tanks, and related accessories screened critical (required)

Confirm oxygen delivery equipment is MRI-compatible and secured according to MRI safety requirements.

Yes No N/A

Emergency support equipment available outside Zone IV as required critical (required)

Confirm emergency equipment needed for the patient is staged in the appropriate non-magnetic location per facility protocol.

Yes No N/A

Clearance, Exceptions, and Final Authorization

Any prohibited item or unresolved concern present critical (required)

Use this item to capture any unresolved implant, device, or external aid concern that would prevent safe entry.

Yes No N/A

Exception approved by radiologist or MRI safety officer critical (required)

If an exception is allowed by policy, document the approving authority and any restrictions.

Yes No N/A

Zone IV entry authorized critical (required)

Confirm the person may enter MRI Zone IV based on completed screening and any required approvals.

Yes No N/A

Inspector signature critical (required)

Signature of the MRI staff member completing the pre-entry safety screen.

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Run: MRI Zone IV Safety Screen

Screening Context and Identity

Implants, Devices, and Conditional Equipment

Personal Items, Clothing, and External Aids

Monitoring, Pumps, and Life Support Equipment

Clearance, Exceptions, and Final Authorization

Get your results