77 Ill. Adm. Code 515.APPENDIX H
H Credentials of Emergency Department Physicians Level I and Level II
Section 515
Section 515.APPENDIX H Â Â 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
Signature
Hospital
CEO/Administrator
Typed
Name
Hospital
CEO/Administrator
Date