PWS Attachment D VAPAHCS Radiology Magnetic Resonance Assessment Form.pdf
PDF 59 KB Posted
- Attached to
- R706--640-20-2-533-0035 | 36Q26120Q0664 | Radiology Building Expansion Activation Services (VA-20-00039396)
- Solicitation number
- 36C26120Q0664
About this file
This document contains a magnetic resonance assessment form and details of a related federal contract opportunity. The assessment form collects health information from individuals, including any metal implants, piercings, or medical history that could impact safety during an MRI scan.
The associated federal contract opportunity is a solicitation from the Department of Veterans Affairs Veterans Health Administration to provide activation services for the VA Palo Alto Health Care System Radiology Building Expansion. The opportunity details include the solicitation number, brief description of required services, and the contracting federal agency. The solicitation seeks activation services to ready the expanded radiology building for use. No further specifics are provided on response dates, pricing, or other contractual terms.
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Other files
| File | Type | Posted |
|---|---|---|
| PWS Corrected - 6.3.pdf | ||
| 36C26120Q0664 0001.docx | DOCX document | |
| Attachment F Facility Map.pdf | ||
| 36C26120Q0664.docx | DOCX document | |
| PWS Attachment B Position Designation System with Glossary 2017.pdf | ||
| PWS Attachment A New FF and E and IT inventory list.pdf | ||
| PWS Attachment E RadCon Furniture Floor Plan.pdf | ||
| PWS Attachment C New FF and E and IT Installation Floor Plans.pdf | ||
| PWS Corrected - 6.3.2020.docx | DOCX document |
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Text version
VAPAHCS RADIOLOGY
MAGNETIC RESONANCE ASSESSMENT FORM
FOR LEVEL 1 - MRI PERSONNEL
Name Date of Birth
Last name ,First name
Male Female Contact Phone Number Service
Date
Date:
Date
Date
1. Are you presently working, or have you ever worked as a machinist, metal worker or in any profession / hobby where you did metal grinding? Yes • No_
2. Have you ever had metal removed from your eyes? Yes No
Please indicate if you have any of the following:
Yes No Aneurysm / Aortic clip(s) Yes No Eye surgery Yes No Cardiac pacemaker Yes No Ear surgery Yes_ !To Implanted defibrillator Yes No Brain surgery Yes No Electronic implant or device Yes No Body pie rcings
Yes No Magnetically-activated implant or device Yes • No Shrapnel or metal
Yes No Neurostimulation system (Tens unit) fragments Yes_ No Spinal cord stimulator Yes No Intra-Uterine device
- Yes No Venous umbrella Yes No Hearing Aid(s)
Yes No Heart valve Yes No Brain clips Yes No Shunt, spinal or ventricular Yes No Any device, wire or
Yes_ No Dentures or partial plates metallic object implanted in your body
I attest that the above information is correct to the best of my knowledge. I understand the contents of this form and had the opportunity to ask questions regarding the information on this form.
Signature of Person Completing Form:
Information Reviewed By:
(Level 2 MRI Personnel)
Signature:
I acknowledged that there are no changes in information provided as reflected on the initial screening:
Signature Date Signature
Signature Date Signature
Distribution: MRI File Version:. 1/06/18
File details come from the government source that posted it. Updated .