Statement from Training Neurophysiologist

This form in its entirety must be completed and signed by the Training Neurophysiologist.

Applicant Name/Degree: ______________________________________________

Qualifications

A qualifying training neurophysiologist is either:

1. An individual with Board Certification from the American Board of Neurophysiologic Monitoring (ABNM). ☐ Please check this box and complete Sections 1, 2, 5 & 6, in their entirety, or,
2. A licensed physician who is Board Certified in Neurology by the ABPN or ABCN. ☐ Please check this box and complete Sections 1, 3, 5 & 6, in their entirety, or,
3. A licensed physician who is Board certified in a specialty other than listed in Qualifications 1 or 2, above, who, depending upon a record of training in Clinical Neurophysiology, may be considered to be deemed appropriate by this Board to serve as a Training Neurophysiologist. ☐ Please check this box and complete Sections 1, 4, 5 & 6, in their entirety. Submit all the required documents listed in Section 4 with this Statement.

In addition to these specific qualifications, the Training Neurophysiologist must attest to a minimum of 5 years' professional experience in intraoperative neurophysiological monitoring (IONM) including at least 2 years of personal supervisory experience in IONM. An individual who functions in the capacity of a "reading neurologist", or "billing provider" or "remote neurologist" or any similar capacity and who otherwise has not directly provided in-person training to the applicant in the interpretation of neurophysiological data, does not qualify to be the applicant's Training Neurophysiologist. A qualified Training Neurophysiologist must have completed the required training of the trainee in-person, for this required training to be deemed eligible by the ABNM.

The statement from the Training Neurophysiologist must attest to the fact that the Training Neurophysiologist conducted training of the applicant trainee for a minimum of twenty-five (25) monitored surgical cases, over a minimum term of ten (10) business days, together and in person with the trainee either in the operating room or at the site of the provision of training in intraoperative neurophysiological services provided remotely or via telemedicine.

Statement

The above-named 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 qualifications and participation in the in-person training of this candidate.

Please complete Section 1 and either Section 2, or Section 3, or Section 4 as appropriate, and Sections 5 and 6, in their entirety, and return this completed, signed and dated form directly to the applicant / trainee. All supporting materials must be included in the candidate's application packet and may not be submitted separately.

Section 1. Please print the following

Name and Degree(s): ___________________________________

Title and/or academic position: ___________________________________

Institution/Employer/Affiliation(s): ___________________________________

Years of IONM experience: ______ years

Years of IONM supervisory experience: ______ years

Check one box: Section 2, 3 or 4

☐ Section 2. Qualified Training Neurophysiologist (ABNM).

Board Certification Number and Date: _________________________________

☐ Section 3. Qualified Training Neurophysiologist (ABPN or ABCN).

☐ Check this box if Fellowship Trained in Clinical Neurophysiology.

Board Certification and Date: ___________________________________

Please submit a copy of your Board Certification, Fellowship Certificate and C.V.

☐ Section 4. Licensed Physician With Other Board Certification.

Board Certification and Date: ___________________________________

Training in IONM / Clinical Neurophysiology:

Submit a copy of your Board Certification, current C.V. and documentation that supports your training in IONM / Clinical Neurophysiology.

Section 5. Training Case Log

To be completed by the Training Neurophysiologist.

Section 6. Attestation

The Training Neurophysiologist must attest to all six statements below.

I have reviewed the material in the application packet being submitted by the above-named applicant including the applicant's case logs. My signature below verifies and attests to these six facts:

1. That the applicant was directly trained by me in person to interpret neurophysiological data, and
2. That this training was conducted together with the trainee, either together with me in the operating room and/or together with me at the site of the provision of remote / telemedicine clinical neurophysiological services, and
3. That the applicant was present and involved in providing the interpretation of data obtained through neurophysiologic intraoperative monitoring during a minimum of twenty-five (25) monitored surgical cases as documented in the Training Case Log, and
4. That the applicant was directly trained by me in person over a minimum term of ten (10) business days as documented in the Training Case Log, and
5. That I functioned as the training neurophysiologist and am listed on the case log/report for each case logged as the neurophysiologist of record, and
6. That I personally and solely was responsible for the completion of all sections of this Statement from Training Neurophysiologist.

I have directly trained the candidate in the interpretation of clinical neurophysiological data in IONM and I fully support this candidate's application for certification by the American Board of Neurophysiologic Monitoring, without reservation.

I attest to the accuracy of the candidate's application to the ABNM.

Signature _____________________________ Date _______________

Printed Name: ________________________________ Degree ______________

The ABNM reserves the right to verify any and all information submitted, as appropriate, in this Statement.