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Petition of Eligibility for EEG Examination
 
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



EEG Education

 YesNo
Did you have didactic (classroom) training?
Did you have clinical training with a supervisor?
Did you participate in monitoring sessions with a senior technologist?
Did you participate in case review sessions with a physician?
Were you required to take a final exam at the end of the training period?
Were you able to monitor EEG cases independently ?

Neurodiagnostic Education

Years of experience in neurodiagnostics: *
EEGs Recorded: *
EEGs Performed: *
Indicate any of the following procedures you personally record: *






Candidates petitioning for eligibility under the expired Pathway IV requirements must submit the following with this petition: (self check off list) *


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