Ill. Admin. Code tit. 77, pt. 515, subpt. K, app H

Current through Register Vol. 48, No. 50, December 13, 2024

Appendix H - Credentials of Emergency Department Physicians Level I and Level II

List each physician by name

Indicate full time or part time

Check all credentials that qualify physician for Illinois Trauma Center Emergency Departments

Physician Name	F= Full Time P= Part Time	ABEM/AOBEM AOA Certified or Eligible	Trauma Center approved prior to 1/1/2000	10 hrs. per year approved CME
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_______________________________________

Signature

Hospital CEO/Administrator

__________________________________________________

Typed NameDate

Hospital CEO/Administrator

Ill. Admin. Code tit. 77, pt. 515, subpt. K, app H

Amended at 25 Ill. Reg. 16386, effective December 20, 2001