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Petition of Eligibility for EP 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 *

Please provide a brief description of your experience in neurodiagnostics: *

Neurodiagnostic Education

	Yes	No
Did you have didactic (classroom) training?	Yes	No
Did you have clinical training with supervision?	Yes	No
Did you participate in record review sessions with a senior technologist?	Yes	No
Did you participate in record review sessions with a physician?	Yes	No
Were you required to take a final exam at the end of your training period?	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.

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

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

Letter from Program Director/Additional upload if needed

Additional upload if needed

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

Please describe why you feel you have had education/experience equivalent to an associate's degree. *

	Yes	No
Are you able to record EEGs/EPs independently?	Yes	No
Have you met the other eligibility requirements under Pathway II or III? (Years of experience, documentation of required cases and ACE credits?)	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.