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ABRET Executive Office
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Petition of Eligibility for CNIM-CS
(Complex Spine Microcredential)
Your Information
Date
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First Name
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Last Name
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Street Address
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Address Line 2
City
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State/Province/Region
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Zip/Postal Code
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Country
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Email Address
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Phone Number
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Employment Information
Hospital/Institution:
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Laboratory/Department/Program Name:
Street Address
City
State/Province/Region
Zip/Postal Code
Manager:
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Manager Email Address
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Manager Phone Number
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Primary reason you are petitioning your Eligibility for the CNIM Complex Spine exam:
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Not all of my cases have been obtained within the required time frame
Other
If other, please explain:
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Please provide a brief description of your reason of petitioning:
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NIOM Experience
Do you hold a current CNIM credential from ABRET?
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Yes
No
Years of experience in spine specific IONM cases:
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1 year
2 to 3 years
4 to 5 years
6 to 10 years
More than 10 years
Please provide a brief description of your Complex Spine experience in Intraoperative Monitoring:
Percent of time currently spent working in Neurophysiologic Monitoring:
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Less than 25%
25% to 75%
More than 75%
Procedure
Indicate any of the following procedures you personally record in the operating room:
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Intradural Tumor Resection (intra and extramedullary)
Extradural/Vertebral Tumor Resection
Spinal Cord Mapping
Adult Deformity Correction
Pediatric Deformity Correction
Tethered Cord Release
Vertebral Column Resection
Pedicle Subtraction Osteotomy
Selective Dorsal Rhizotomy
Unstable high cervical fracture
High grade (4 or 5) spondylolisthesis
Modalities
Indicate any of the following modalities you personally record in the operating room:
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D-wave
Descending Neurogenic Evoked Potentials
Bulbocavernosus Reflex Monitoring
Spinal WADA
SSEP Collision Study
Dermatomal SSEP
Saphenous Nerve SSEP
Pudendal SSEP
Dorsal Column Mapping
Upload letter of recommendation/Additional upload if needed
Upload Complex Spine IOM cases here
Need an IOM Documentation Form? Click here.
A $15.00 fee is required for submission and review of this form
*
Petition Review Fee ($15.00)
*continue to the next page for submission and fee.
ABRET/ABCN | 111 E. University Dr. #105-355 | Denton, TX 76209 | ph/fax 217.726.7980