Ill. Admin. Code tit. 77, § 515.APPENDIX G
List each surgeon by name
Check appropriate categories regarding trauma care experience and operating room privileges
Signed by CEO/Hospital Administrator
| Surgeon Name | T = Trauma Surgeon G = General Surgeon | Two years post-residency trauma care experience | Independent OR privileges | 20 hrs. for every two years trauma-related CME | ||||
| Signature Hospital CEO/Administrator | ||||||||
| Typed Name Hospital CEO/Administrator | Date |
(Source: Amended at 25 Ill. Reg. 16386, effective December 20, 2001)