New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 7th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Sleep Studies for Technician (Renewal)
I attest that __________________________________________________ has completed _____________________
(Name of applicant) (Number of studies)
sleep studies as a licensed polysomnographic technician over the last ______________________ months beginning
(Number of months)
________________ ending _______________ at _____________________________________________________,
(Month, Day, Year) (Month, Day, Year) (Name of facility)
______________________________________________________________, ______________________________,
(Address, City, ZIP Code) (Telephone number)
which is provisionally or fully accredited by the American Academy of Sleep Medicine (A.A.S.M.).
_______________________________________________
Print name of licensed polysomnography technologist
or qualied medical director
_______________________________________________ ____________________________________
Signature of licensed polysomnography technologist Date (Month, Day, Year)
or qualied medical director
_______________________________________________ ____________________________________
License number of licensed polysomnography technologist Date of license expiration (Month, Day, Year)
or qualied medical director
Please note:
N.J.A.C. 13:44L-1.2 denes a “qualied medical director” as a licensed physician who is either eligible for board
certication or is board certied in sleep medicine by the American Board of Sleep Medicine, or a certication board
recognized by the American Board of Medical Specialties which bases its certication in sleep medicine upon the sleep
medicine examination created by the American Board of Internal Medicine, and who acts as the medical director of any:
1. In-patient or out-patient sleep center or laboratory provisionally accredited or fully accredited by the A.A.S.M. or
accredited by a Joint Commission;
2. Ambulatory care facility or general acute care hospital licensed by the Department of Health and Senior
Services;
3. Home health agencies, assisted living residences, comprehensive personal care homes, assisted living programs
and alternate family care sponsor agencies licensed by the Department of Health and Senior Services; or
4. Health care service rms registered with the Division of Consumer Affairs.
N.J.A.C 13:44L-3.3 (c).4 Documentary proof signed by a supervising polysomnographic technologist or qualified
medical director indicating that, within the last year, the applicant has completed at least 100 sleep studies in a
facility that is provisionally or fully accredited by A.A.S.M. If you have completed these sleep studies in more than
one facility, submit one form for each facility.
(Attach additional copies as necessary.)
Rev. 7/27/20
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