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Petition of Eligibility for EEG or EP Examinations
 
Use this form if:
 

1. You have had structured of formal training in neurodiagnostics, but have not earned a degree.

2. You can substantiate education equivalent to at least an associate's degree (foreign medical degree, or vocational education in healthcare field).

3. You have a combination of college credits and medical experience.

 
*Structured is defines as any organized learning institution or program that has defined class work, core instruction and measurable outcomes. On the job training is NOT considered structured learning.

Your Information



Employment Information



Neurodiagnostic Education

 YesNo
Did you have didactic (classroom) training?
Did you have clinical training with supervision?
Did you participate in record review sessions with a senior technologist?
Did you participate in record review sessions with a physician?
Were you required to take a final exam at the end of your training period?






Other Healthcare Education

 YesNo
Did you have didactic (classroom) training?
Did you have clinical training with supervision?
 YesNo
Are you able to record EEGs/EPs independently?
Have you met the other eligibility requirements under Pathway II or III? (Years of experience, documentation of required cases and ACE credits?)


A $15.00 fee is required for submission and review of this form *
*continue to the next page for submission and fee.