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

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

Appendix I - Credentials of General/Trauma Surgeons Level I and Level II Pediatric Trauma Centers

List each surgeon by name

Check appropriate requirements met

Signed by CEO/Hospital Administrator

Surgeon Name	Meets requirements of Section 515.2035(b) or 515.2045(b)	Meets requirements of Section 515.2035(c) or 515.2045(c)
________	________	________
________	________	________
________	________	________
________	________	________
________	________	________
________	________	________
________	________	________
________	________	________
________	________	________
________	________	________

_______________________________________

Signature

Hospital CEO/Administrator

__________________________________________________

Typed NameDate

Hospital CEO/Administrator

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

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