CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS (APPENDIX 5)

ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS  List each physician by name.  Indicate full time or part time and date of ED hire.  Check all credentials that qualify physician for EDAP or SEDP status.  Identify any physicians that may have received a waiver from IDPH.  For all physicians who do not meet any of the Board Certifications listed below and do not have a waiver, submit CV, other Board Certifications and copies of their Residency Completion.  Identify completion of APLS or PALS.  Write the number of pediatric CME hours that have been completed within the past 2 years.

Certification * Course Ex Ex F=Full (Or Board Eligible in 1st cycle) Completion 16 HRS. of Pediatric Date p. Physician Name ABEM, AOBEM, ABP, AOBP, ABFP or Emergency related CME Dat Dat AOBFP APLS PALS (In last two years) (Identify if waiver requested/obtained)

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.) CREDENTIALS OF FAST TRACK/URGENT CARE PHYSICIANS (APPENDIX 6)

PCCC APPLICATION AND EDAP RENEW AL PACKET 1 ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF FAST TRACK/URGENT CARE PHYSICIANS

 List each physician by name.  Indicate full time or part time and date of ED hire.  Check all credentials that qualify physician for EDAP or SEDP status.  Identify any physicians that may have received a waiver from IDPH.  For all physicians who do not meet any of the Board Certifications listed below and do not have a waiver, submit CV, other Board Certifications and copies of their Residency Completion.  Identify completion of APLS or PALS.  Write the number of pediatric CME hours that have been completed within the past 2 years.

Certification * Course Ex Ex F=Full (Or Board Eligible in 1st cycle) Completion 16 HRS. of Pediatric Date p. Physician Name ABEM, AOBEM, ABP, AOBP, ABFP or Emergency related CME Dat Dat AOBFP APLS PALS (In last two years) (Identify if waiver requested/obtained)

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 2 CREDENTIALS OF EMERGENCY DEPARTMENT MID LEVEL PROVIDERS (APPENDIX 7)

ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF EMERGENCY DEPARTMENT NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS

 List each Nurse Practitioner and/or Physician Assistant by name.  Indicate full time or part time and date of ED hire.  Check all credentials and verify current license.  Nurse Practitioners shall have completed a Pediatric NP, Emergency NP or Family Practice NP program (or meet waiver criteria identified in 515.4000 or 515.4010, b, l, A, i).  Identify completion of APLS, PALS or ENPC.  Write the number of pediatric CME/CEU that have been completed within the past 2 years. License Verification * 16 HRS. of Pediatric F=Full Date Facility Course Completion NP = Illinois Advanced Exp. Emergency of Credentialing Exp. Provider Name Practice License Date CME/CEU ED For Pediatric Date P=Part (PNP, ENP, FPNP) ENP (In Last Two Years) Hire Care APLS PALS Time PA = Illinois License C

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 3 CREDENTIALS OF EMERGENCY DEPARTMENT NURSING STAFF (APPENDIX 8)

ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF EMERGENCY DEPARTMENT NURSING STAFF

 List each staff nurse by name.  Indicate full time or part time and date of ED hire.  Identify completion of APLS, PALS or ENPC.  Write the number of pediatric CEU’s that have been completed within the past 2 years.

Course Completion 8 HRS. of Pediatric Emergency/Critical F=Full Time Expiration Care CEU’s (In Last Two Years) Staff Nurse Date of ED Hire P=Part Time APLS PALS ENPC Date EDAP – All RN’s SEDP – One RN/Shift

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 4 CREDENTIALS OF PEDIATRIC INTENSIVE CARE UNIT PHYSICIANS (APPENDIX 9)

ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF PEDIATRIC INTENSIVE CARE UNIT PHYSICIANS

 List each physician by name.  Indicate full time or part time.  Provide copy of Board Certification for each physician.  Identify completion of APLS or PALS course and expiration date.

F=Full Course T Completion i m e

Date of Certification as Pediatric Intensivist with Dual P H = Certifications: ABP and Pediatric Critical Care Exp. Exp. Physician Name i P Medicine or AOBP and Pediatric Intensive Care Date Date r a or Board Eligible Pediatric Intensivist APLS PALS r e t

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 6 CREDENTIALS OF PICU MID LEVEL PROVIDERS (APPENDIX 10)

ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF PICU NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS

 List each Nurse Practitioner and/or Physician Assistant by name.  Indicate full time or part time.  Indicate NP or PA licensure and expiration date.  Nurse Practitioners shall have completed a Pediatric NP or Pediatric Critical Care NP program.  Identify completion of APLS, PALS or ENPC.  Note the number of pediatric CME/CEU that have been completed within the past two years.

License Verification * Nurse F=Full Pediatric/Critical Care Date NP = Illinois Advanced Exp. Practitioner Course Completion Exp. 50 Hours Provider Name of Practice License Date (Check one) Date CME/CEU ** P=Part Hire ENP PNP PCCNP APLS PALS (In Last Two Years) Time PA = Illinois License C

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 7 ** Physician Assistant CME’s must be from ACCME, AOCCME, AAFP or AAPA

PCCC APPLICATION AND EDAP RENEW AL PACKET 8 CREDENTIALS OF PICU NURSING STAFF (APPENDIX 11)

ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF PICU NURSING STAFF

 List each staff nurse by name.  Indicate full time or part time and date of hire.  Identify completion of APLS, PALS or ENPC.  Note the number of pediatric CEU’s that have been completed within the past two years.

F=Full Time Course Completion Expiration 16 HRS. of Pediatric CEU’s Staff Nurse Date of ED Hire P=Part Time APLS PALS ENPC Date (In Last Two Years)

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 9 CREDENTIALS OF PEDIATRIC UNIT HOSPITALISTS (APPENDIX 12) ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF PEDIATRIC UNIT HOSPITALISTS

 List each physician by name.  Indicate full time or part time.  Provide copy of Board Certification for each physician.  Identify completion of APLS or PALS course and expiration date.

F=Full Course T Completion i m e

Date of P H = Exp. Exp. Physician Name i Board Certification P Date Date a r APLS PALS r e t

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 11 CREDENTIALS OF PEDIATRIC UNIT NURSING STAFF (APPENDIX 13) ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN EDAP/PCCC APPLICATION CREDENTIALS OF PEDIATRIC UNIT NURSING STAFF

 List each staff nurse by name.  Indicate full time or part time and date of hire.  Identify completion of APLS, PALS or ENPC.  Note the number of pediatric CEU’s that have been completed within the past two years.

F=Full Time Course Completion Expiration 16 HRS. of Pediatric CEU’s Staff Nurse Date of ED Hire P=Part Time APLS PALS ENPC Date (In Last Two Years)

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______Signature Typed Name Date Hospital CEO/Administrator Hospital CEO/Administrator

(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)

PCCC APPLICATION AND EDAP RENEW AL PACKET 12