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Petition of Eligibility for CNIM

Your Information

Date *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address *

Phone Number *

Employment Information

Hospital/Institution: *

Laboratory/Department/Program Name:

Street Address

City

State/Province/Region

Zip/Postal Code

Instructor/Manager: *

Instructor/Manager Email Address *

Instructor/Manager Phone Number *

Primary reason your are petitioning your Eligibility for the CNIM exam: *

If other, please explain: *

Please provide a brief description of your experience in Neurodiagnostics/NIOM: *

NIOM Education

What were your dates of training?

	Yes	No
Did you have didactic (classroom) training?	Yes	No
Did you have clinical training with supervision?	Yes	No
Did you participate in monitoring sessions with a senior technologist?	Yes	No
Did you participate in case review sessions with a physician?	Yes	No
Were you required to take a final exam at the end of your training period?	Yes	No
Are you able to monitor NIOM cases independently?	Yes	No
Have you completed documentation of 150 cases?	Yes	No

If you responded YES to any of the above questions, please describe how much time was devoted to these activities on a weekly basis.

Years of experience in neurodiagnostics: *

Please provide a brief description of your experience in Intraoperative Monitoring:

Percent of time currently spent working in Neurophysiologic Monitoring: *

Less than 25%

25% to 75%

More than 75%

Indicate any of the following procedures you personally record in the operating room: *

Upload transcript or other education documentation (diploma, certificate etc.) *

Upload letter from program director/Additional upload if needed

Upload IOM cases here

Additional upload if needed

Need an IOM Documentation Form? Click here.

Other Healthcare Education

What kind of healthcare education have you successfully completed?

What were your dates of training?

	Yes	No
Did you have didactic (classroom) training?	Yes	No
Did you have clinical training with supervision?	Yes	No

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.