APPENDIX A
STATEMENT FROM SUPERVISING NEUROPHYSIOLOGIST
STATEMENT FROM SUPERVISING NEUROPHYSIOLOGIST
Applicant Name/Degree: ______________________________________________
A qualifying supervising neurophysiologist is either an individual with Board Certification from the American Board of Neurophysiologic Monitoring, or, a licensed physician who is Board Certified in Neurology by the American Board of Psychiatry and Neurology and who has Fellowship training in Clinical Neurophysiology including intraoperative neurophysiological monitoring. The supervising neurophysiologist must attest to a minimum of 3 years experience in intraoperative neurophysiological monitoring (IONM) including at least 2 years of supervisory experience in IONM. Exceptions to the qualifications of the supervising neurophysiologist may be made at the discretion of the Board and/or the Review Committee of the Board.
The above candidate is applying for certification by the American Board of Neurophysiologic Monitoring (ABNM). A requirement of the application process is this form attesting to your participation in the supervision and training of the candidate.
Please indicate the appropriate response to each of the following questions:
Name and Highest Degree: ___________________________________
Board Certification and Date: ___________________________________
Title and/or academic position : ___________________________________
Institution/Employer/Affiliation(s): ___________________________________
Years of IONM supervisory experience: ___2-5 ___6-10 ___>10 years
Over how long a period of time (in years and months) AND in how many surgical procedures (in numbers of procedures) have you directly trained the candidate in the interpretation of clinical neurophysiological data in IONM?"
Over ____ years and ___ months and _____ procedures.
I have reviewed the material being submitted by the above named applicant including the applicant's case log. My signature below verifies that the applicant was supervised by me and was present and involved in providing interpretation of data obtained through neurophysiologic intraoperative monitoring during those surgical cases where I am listed as the supervising neurophysiologist on the case log. I fully support this candidate's application for certification by the American Board of Neurophysiologic Monitoring, without reservation and I attest to the accuracy of the candidate's application to the ABNM.
Signature _____________________________ Date _______________
Please return this form directly to: Professional testing Corporation
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