Ill. Admin. Code tit. 77, § 515.APPENDIX H
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 |
(Source: Amended at 25 Ill. Reg. 16386, effective December 20, 2001)