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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

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 you are petitioning your eligibility for the EEG exam: *

Briefly explain the reason you are unable to fulfill the requirements:

EEG Education

What were your dates of training?

	Yes	No
Did you have didactic (classroom) training?	Yes	No
Did you have clinical training with a supervisor?	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 the training period?	Yes	No
Were you able to monitor EEG cases independently ?	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:

Neurodiagnostic Education

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

Please list the dates which you attended college, any degrees earned, and how many hours you completed:

Years of experience in neurodiagnostics: *

Provide a brief description of your experience in Electroencephalography: *

EEGs Recorded: *

EEGs Performed: *

ALL analog

ALL digital

Both analog and digital but PRIMARILY ANALOG

Both analog and digital but PRIMARILY DIGITAL

Indicate any of the following procedures you personally record: *

Upload educational documents such as diploma, transcripts, certificates, etc. *

Upload required EEG cases utilizing the ABRET EEG Documentation Form

Upload letter of recommendation

Additional upload if needed

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

200 EEGs documented and signed. Must be dated within the last 5 years with 50 in the last 12 months

60 ASET credits in EEG. Dated within the last 5 years

Current CPR/BLS

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.