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LAB-LTM Application
LAB-LTM: Epilepsy Monitoring and ICU/Critical Care EEG Monitoring
ACCREDITATION APPLICATION PART I
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I. Program Overview
Date Application Submitted
Hospital/Institution
Department Name
First & Last Name
Current Title
Street Address
Address Line 2 (include Mail Code or Mail Stop)
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Phone Number
Email Address
Yes
No
Is your EEG Laboratory an accredited ABRET LAB-EEG?
Yes
No
Epilepsy
Critical Care
Both
With invasive recordings
Are you Applying for LTM Epilepsy Monitoring, Critical Care EEG Accreditation or both?
Epilepsy
Critical Care
Both
With invasive recordings
Yes, as a level I center
Yes, as a level II center
Yes, as a level III center
Yes, as a level IV center
No, but we plan to apply
No with no plans to apply
Do you currently hold accreditation through the National Accreditation of Epilepsy Centers (NAEC)?
Yes, as a level I center
Yes, as a level II center
Yes, as a level III center
Yes, as a level IV center
No, but we plan to apply
No with no plans to apply
Epilepsy Monitoring
Not applicable
Medical Director
Phone Number
Email Address
Technical Director (or equivalent)
Phone Number
Email Address
Administrator/Title
Phone Number
Email Address
ICU/Critical Care EEG
Not applicable
Medical Director
Phone Number
Email Address
Technical Director (or equivalent)
Phone Number
Email Address
Administrator & Title
Phone Number
Email Address
II. Volume
Epilepsy Monitoring
Yes
No
N/A
Diagnostic/Pre-surgical (scalp)
Yes
No
N/A
Invasive extraoperative monitoring
Yes
No
N/A
Adult
Yes
No
N/A
Pediatric
Yes
No
N/A
Do you taper AEDs during admission
Yes
No
N/A
Total number of epilepsy monitoring procedures done in last year
Of the total above, how many were Diagnostic/Pre-surgical?
Of the total above, how many were Invasive extraoperative monitoring
Of the total above, how many were Invasive extraoperative monitoring
ICE/Critical Care EEG
Yes
No
N/A
Adult
Yes
No
N/A
Pediatric
Yes
No
N/A
Neonates
Yes
No
N/A
Total number of procedures done in last year
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.
Name/Degree(s)
Boards
ABPN
ABCN
ABPN-CNP
Other
Participation in:
EMU
ICU/CC EEG
Name/Degree(s)
Boards
ABPN
ABCN
ABPN-CNP
Other
Participation in:
EMU
ICU/CC EEG
Name/Degree(s)
Boards
ABPN
ABCN
ABPN-CNP
Other
Participation in:
EMU
ICU/CC EEG
Name/Degree(s)
Boards
ABPN
ABCN
ABPN-CNP
Other
Participation in:
EMU
ICU/CC EEG
Name/Degree(s)
Boards
ABPN
ABCN
ABPN-CNP
Other
Participation in:
EMU
ICU/CC EEG
Name/Degree(s)
Boards
ABPN
ABCN
ABPN-CNP
Other
Participation in:
EMU
ICU/CC EEG
LTM Monitoring Technologist
List all tehnologists participating in LTM
Name
Boards
CLTM
R. EEG T./R.E.T.
CNIM
None
Participation in:
EMU
ICU
Name
Boards
CLTM
R. EEG T./R.E.T.
CNIM
None
Participation in:
EMU
ICU
Name
Boards
CLTM
R. EEG T./R.E.T.
CNIM
None
Participation in:
EMU
ICU
Name
Boards
CLTM
R. EEG T./R.E.T.
CNIM
None
Participation in:
EMU
ICU
Name
Boards
CLTM
R. EEG T./R.E.T.
CNIM
None
Participation in:
EMU
ICU
Name
Boards
CLTM
R. EEG T./R.E.T.
CNIM
None
Participation in:
EMU
ICU
111 E. University Dr. #105-355 | Denton, TX 76209 | ph/fax 217.726.7980