Ill. Admin. Code tit. 77, pt. 515, subpt. K, app B
a) Name and address of hospital
_______________________________________
_______________________________________
_______________________________________
_______________________________________
b) Designation renewal level for which your hospital is applying:
1) Level I
2) Level II
Any change in designation level requires that the appropriate Request for Designation (RFD) Trauma Center be completed.
c) The above named facility certifies that each requirement listed in this Request for Renewal of Trauma Center Designation is met.
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Signature CEO/AdministratorDate
_______________________________________
Signature Trauma DirectorDate
_______________________________________
Contact person and phone number
d) Provide updated copies of all documents submitted for the most recent designation application or renewal request as outlined in Section 515.Appendix A for Level I or for Level II, items 1-11. This will constitute an updated Trauma Plan. The plan must be submitted in the order listed. Each item in the Trauma Plan must reference the applicable portion of this Part by subsection number.
e) Provide copies of minutes, on site or upon request, from any committees that are involved in focused outcome analysis for the most recently completed three months. All information contained in or relating to any medical audit performed of a Trauma Center's trauma services...shall be afforded the same status as is provided information concerning medical studies in Article VIII, Part 21, of the Code of Civil Procedure. (Section 3.110 of the Act)
f) Medical records may be requested to complete the renewal request.
Ill. Admin. Code tit. 77, pt. 515, subpt. K, app B