Candidate Name: ________________________________
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 the experience of the candidate.
Please indicate the appropriate response to each of the following questions:
How long have you known the candidate (in years)? ____
Your surgical specialty _________________
In which hospital(s) have you worked with the candidate?
Approximately how many operative monitoring cases have you conducted with the candidate?
- 0-10
- 11-25
- 26-50
- 51-100
- over 100
Region(s) of the nervous system where monitoring has been conducted with you:
- Spine
- Brainstem
- Cortical
- Peripheral nerve/plexi
Comments:
I support this candidate’s Application for the ABNM Certification Examination in Intraoperative Neurophysiologic Monitoring.
Signature _________________________________________ Date ___________
Printed Name _____________________________________
Position ______________________________ Telephone Number ______________
Please include this form with your complete application packet and email it to PTC at: eforms@ptcny.com