LAB-LTM Application

LAB-LTM: Epilepsy Monitoring and ICU/Critical Care EEG Monitoring

ACCREDITATION APPLICATION PART I

Form Login Account (optional)
New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.

I. Program Overview
 YesNo
Is your EEG Laboratory an accredited ABRET LAB-EEG?
 EpilepsyCritical CareBothWith invasive recordings
Are you Applying for LTM Epilepsy Monitoring, Critical Care EEG Accreditation or both?
 Yes, as a level I centerYes, as a level II centerYes, as a level III centerYes, as a level IV centerNo, but we plan to applyNo with no plans to apply
Do you currently hold accreditation through the National Accreditation of Epilepsy Centers (NAEC)?

Epilepsy Monitoring


ICU/Critical Care EEG



II. Volume
Epilepsy Monitoring
 YesNoN/A
Diagnostic/Pre-surgical (scalp)
Invasive extraoperative monitoring
Adult
Pediatric
Do you taper AEDs during admission
ICE/Critical Care EEG
 YesNoN/A
Adult
Pediatric
Neonates


III. Personnel

Medical Director: Complete CV form (Appendix 1)
Technical Director (or equivalent): Complete CV form (Appendix 2)
 
Interpreting Physicians

List all the Physicians involved with interpreting EEG data collected for Epilepsy and ICE/Critical Care EEG monitoring.
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:

LTM Monitoring Technologist

List all tehnologists participating in LTM
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
Boards
Participation in:
111 E. University Dr. #105-355 | Denton, TX 76209 | ph/fax 217.726.7980