MRI-FRM-001: MRI safety screening record

Standards › Standard 50 › Forms

Form · MRI-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 50.5

Purpose

Records the MRI contraindication screen for each patient and each accompanying person before they enter the magnetic field.

How to complete

• Ask the screening questions to the patient and each accompanying person.
• Check any implant or device against the MRI-conditional list.
• Record the decision to enter or not, and who made it.

Checks

Check	Entry
Patient or accompanying person	Yes
Screening questions completed	Yes
Implant or device checked (yes or no)	Yes
Cleared to enter (yes or no)	Yes
Screened by and date	Yes

Evidence

Reference	Note
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

• Diagnostic Imaging Safety and Quality Standards (AMB-16)

References

• Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
• Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)