Evaluation Form

For MRI Stereo Sound System

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MRI Stereo Sound System Pre-Planning Evaluation Form
Enables Customization and Planning for Your MRI Facility

Please have your M.R.I. installation personnel or Site-Engineer complete the following evaluation form so that you may place your MRI Patient Stereo System order. This data will be used as a guideline in manufacturing the required cables and creation of the installation manual for your MRI scanning facility. This form may be completed online, and submitted directly to Scan Sound, or you may download the form and fax it to (954) 827-2408 if you wish. Click here If you prefer to download an Adobe Acrobat version of this form, print it out and fax the completed form to Scan Sound. Download:

Please use the following diagram as a guide to assist you
with determining the most appropriate cable lengths.

The above diagram shows the typical cable connections inside the scan room, going from the RF Penetration Panel to the Patient Acoustic Interface. This may visually help you to understand how to fill out the form.

Please Complete and Submit the Form Below:

Name of Your MRI Facility
Department
Phone Number
Street Address
City
State
Zip
Contact Person
E-mail Address of Contact Person
MRI System Manufacturer
Model/Type of MRI System
Field Strength of Magnet
Type of Magnet	Shielded Unshielded
Person Who Completed This Questionnaire
Responding Person's E-mail Address
Responding Person's Phone Number

Does Your System Currently Have Two Spare BNC Connectors?	Yes No

What Length of Cable Will Be Required to Run From the Stereo System to the Scan Room Bulkhead Connector Panel?
Cables M & N Will Be:

What length of cable will be required to run from the RF Connector Panel to a location for the Patient Acoustic Interface at the Base of the Magnet?
Cables T & U Will Be:

How long should the microphone cord be to go from the stereo to the Operator's Console?
Choose from the Following Lengths:	6 Feet 12 Feet 25 Feet

Please Enter any Comments or Questions of Concern Below:

When you have finished filling out the form, please click the SUBMIT button.

Thank you very much!

If you would like to make your measurements and fax the completed form to Scan Sound afterward, click on the button below to Print Out the Web Page

You may fax your completed form to (954) 827-2408

Evaluation Form

Please Complete and Submit the Form Below:

When you have finished filling out the form, please click the SUBMIT button.