Ill. Admin. Code tit. 77, pt. 515, subpt. K, app J
Current through Register Vol. 48, No. 50, December 13, 2024
List each physician by name
Indicate full 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 Prepared (ED Director must be certified) | 10 hrs. per year approved CME & daily involvement in pediatric trauma care |
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_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
_____ | _____ | _____ | _____ |
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Signature
Hospital CEO/Administrator
__________________________________________________
Typed NameDate
Hospital CEO/Administrator
Ill. Admin. Code tit. 77, pt. 515, subpt. K, app J