Please fill out this form to request an approval by the CMRR MR Professionals group. This form replaces the process of emailing the MR Professionals or tracking them down in person for a signature. It does not change when you need to obtain that approval.
Not all affirmative answers on the screening form require approval by the CMRR Professionals:
- items in section 1 should initiate a conversation with the subject; your goal is to determine if they may have implants or conditions that are contraindicated or require approval from the MR Professionals group
- items in section 2 may be approved by authorized study staff, the PI, a CMRR MR Technologist, or the MR Professionals group
- items in section 3 (with the exception of Mirena, Paragaurd, and Skyla brand IUDs) require approval from the MR Professionals group and must be included
You may include items from section 1 or 2 if you are unsure about their safety, but you do not have to include them. Please refer to the following resources for more details:
You will need to gather the following information:
- Scan Date
- Scanner(s)
- RF Coil(s)
- Imaging Anatomy
- project number
For each implant or surgery you are unsure about:
- brief description (i.e. "lumbar fusion" or "broken wrist")
- location of implant in body
- year of surgery (if less than 1 year, include month)
- location of surgery (was it done in the US or elsewhere)
-
What the surgery was for (important when implant details are not known)
- implant details if applicable, including manufacturer, model number, geometry, and material
- Information from manufacturer regarding the MR compatibility of implant
Note that a copy of the surgical report may be required depending on implant, and that all such information must be de-identified
If you are on a mobile device and do not see a "next" button after completeing the Capcha, enable landscape mode (turn your device sideways)
