ࡱ> uxrst 3bjbj Hhhk)\,8 8 8N2:!!!02222222222222$[4 7*V2V$ !V$V$V2$k2+++V$02+V$02++:0,h 1#- +$0 22020R78%78 178 1!"|+ #d#!!!V2V2(!!!2V$V$V$V$78!!!!!!!!!8 X: 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. Physician NameF=Full Time P=Part TimeDate of ED HireCertification * (Or Board Eligible in 1st cycle) ABEM, AOBEM, ABP, AOBP, ABFP or AOBFP (Identify if waiver requested/obtained)Exp. DateCourse CompletionExp. Date16 HRS. of Pediatric Emergency related CME (In last two years)APLSPALS 1  2  3  4  5  6  7  8  9   10  ______________________________________ ______________________________________ ______________ 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.)  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. Physician NameF=Full Time P=Part TimeDate of ED HireCertification * (Or Board Eligible in 1st cycle) ABEM, AOBEM, ABP, AOBP, ABFP or AOBFP (Identify if waiver requested/obtained)Exp. DateCourse CompletionExp. Date16 HRS. of Pediatric Emergency related CME (In last two years)APLSPALS 1  2  3  4  5  6  7  8  9   10  ______________________________________ ______________________________________ ______________ 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.) 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. Provider NameF=Full Time P=Part TimeDate of ED HireLicense Verification * NP = Illinois Advanced Practice License (PNP, ENP, FPNP) PA = Illinois LicenseExp. Date Facility Credentialing For Pediatric CareCourse CompletionExp. Date16 HRS. of Pediatric Emergency CME/CEU (In Last Two Years) APLSPALSENPC 1  2  3  4  5  6  7  8  9  10  ______________________________________ ______________________________________ ______________ 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.) 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 CEUs that have been completed within the past 2 years. Staff NurseF=Full Time P=Part TimeDate of ED HireCourse CompletionExpiration Date8 HRS. of Pediatric Emergency/Critical Care CEUs (In Last Two Years) EDAP All RNs SEDP One RN/ShiftAPLSPALSENPC 1  2  3  4  5  6  7  8  9  10  11  ______________________________________ ______________________________________ ______________ 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.)  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. Physician NameF=Full Time P=Part TimeDate of HireCertification as Pediatric Intensivist with Dual Certifications: ABP and Pediatric Critical Care Medicine or AOBP and Pediatric Intensive Care or Board Eligible Pediatric IntensivistExp. DateCourse CompletionExp. DateAPLSPALS 1  2  3  4  5  6  7  8  9  10  ______________________________________ ______________________________________ ______________ 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.) 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. Provider NameF=Full Time P=Part TimeDate of HireLicense Verification * NP = Illinois Advanced Practice License PA = Illinois LicenseExp. Date Nurse Practitioner (Check one)Course CompletionExp. DatePediatric/Critical Care 50 Hours CME/CEU ** (In Last Two Years)PNPPCCNPAPLSPALSENPC 1  2  3  4  5  6  7  8  9  10  ______________________________________ ______________________________________ ______________ 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.) ** Physician Assistant CMEs must be from ACCME, AOCCME, AAFP or AAPA 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 CEUs that have been completed within the past two years. Staff NurseF=Full Time P=Part TimeDate of ED HireCourse CompletionExpiration Date16 HRS. of Pediatric CEUs (In Last Two Years)APLSPALSENPC 1  2  3  4  5  6  7  8  9  10  11  ______________________________________ ______________________________________ ______________ 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.) 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. Physician NameF=Full Time P=Part TimeDate of HireBoard CertificationExp. DateCourse CompletionExp. DateAPLSPALS 1  2  3  4  5  6  7  8  9  10  ______________________________________ ______________________________________ ______________ 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.) 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 CEUs that have been completed within the past two years. Staff NurseF=Full Time P=Part TimeDate of ED HireCourse CompletionExpiration Date16 HRS. of Pediatric CEUs (In Last Two Years)APLSPALSENPC 1  2  3  4  5  6  7  8  9  10  11  ______________________________________ ______________________________________ ______________ 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.)     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