§515.APPENDIX H. Credentials of Emergency Department Physicians Level I and Level II

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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)

                    
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