UCLA Brain Mapping Center

Scan Time: *
1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM

Prisma Scanner Room
       Turned on scanner bore fan for at least 15 minutes post scan
       Coil top and bottom
       Mirror or goggles
       Button box
       Headphones
       Squeeze ball
       Non disposable cushions
       Physio holders, pulse and respiratory devices, pen panel cables, decals if applicable
       Prescription lenses/glasses if used
       Scanner bed
       White cart counter and drawers handles
       Mask basket
       Hand sanitizer
       Sand bags
       Scanner controls both sides
       Countertops
       Cabinet handles
       Remove and replace linen bag if full
       Linen hamper lid
       Remove and replace bed paper trash if full
       Inside bore
       Floor
       Sink handle, switch and soap dispenser
       Wipes, spray bottle and swiffer stick
       Scanner room inside door handle

Did your subject use the changing room? Yes No

Changing Room
       Outer door handle
       Inner door handle
       Chair
       Locker door & handle
       Locker key
       Inside of locker
       All counters
       Remove and replace linen bag if full
       Linen hamper lid
       Cabinet handles
       Bioscrypt finger area and keypad

Did your subject use the bathroom? Yes No

Subject Bathroom
       Outside bathroom door handle
       Sink
       Sink knobs
       Soap dispenser
       Toilet handle
       Toilet seat
       Hand rail
       Paper towel dispenser wheel
       Door hook
       Inside door handle

Hallway
       Data lab Bioscrypt finger area and keypad
       Purell dispenser
       On/off switch for ferroguard
       Back door handles inside and out
       Lobby door handles inside and out

Control Room
       Scanner room outside door handle
       Scanner room light switch
       Phone if used
       Dell keyboard and mouse/pad
       Dell switch box buttons
       Console keyboard and mouse/pad
       Intercom(s) – siemens and opto
       Mac keyboard
       Button box interface knob
       LCD interface buttons
       Cables and adapters (hdmi, audio, trigger, vga, epi)
       iPod holder
       iPod
       Counter
       Laminated instruction sheets
       Chair
       Back desk if used
       Cabinet handles
       Prescription lenses case if used
       Supply cart
       Thermometer
       Purell dispenser
       Light switch
       Bungee cord
       Empty data lab and prisma trash bins into the large hallway trash
       Control room wipes and spray bottle
       Control room door handle inside and out
       Bioscrypt finger area and keypad
       Clean face shield, personal phone and wash hands

Notes: