Ill. Admin. Code tit. 77, § 515.APPENDIX J
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 | ||||||
| Signature Hospital CEO/Administrator | |||||||||
| Typed Name Hospital CEO/Administrator | Date | ||||||||
(Source: Added at 25 Ill. Reg. 16386, effective December 20, 2001)