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Ambrose Felix Fletcher
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19 Clinical Privileges Update Form Linda Duska Department of Obstetrics and I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type ofexperience): Current Privileges not to be Renewed: * ~ _..._--_..._-- -_._-_._------_..._-_._-_..._-_..._--_..._--_..._-_......_- *Prlvileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. DATE [ I -\: -::7''-.l '---y-''-::d---==''r As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level ofexperience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Sincejhe date ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We ~mas follows:.. I Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted but restricted as follows: ~-;;A;f/-flll ~(B( t\ DATE Reviled 3/112006

20 m Co~nllttee Clinical Privileges Update Form Linda Duska Department of Obstetrics and GY~~ I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): The Chai~ of the Department of Obstetr'ics and-gynecology;-(james E. Ferguson III, M.D.) reviewed and approved Dr. Duska's request on 2/8/11. The ne~ privileges noted above were reviewed and approved by the Credentials at their-3ll1l2011 meeting. T-IwClinieal StaffExecutive Committee reviewed an~roved these privileges 9n 3/15/201L ~ ~ Documelltation is available ld Dr-:-DiiSKa'sCredentialing Filein the Clinical Staff Credentials Committee Action Date: 3/11/2011 Clinical Staff Executive Committee Action Date: 3/15/2011 Medical Center Operating Board Action~- Date: 6/09/2011

21 Clinical Privileges Update Form Linda Dnska Department of Obstetrics and I have reviewed the privileg(:s previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): --_._--_.._ ~ Current Privileges not to be Renewed:* r;p;i~i~;;~ not renewed are not reported as being voluntarily relinquished unless done you are under investigation; in return for not conducting an in7estigation or proceeding. Ifprivileges are to be reported as voluntarily relinquished you be notified and receive a copy of l;he report to be filed with the National P aditioner Databank. ~L{\v?{~ DATE CLINICIAN SIGNATURE As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of expe;rience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ' We find as follows: l~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. DEPARTMENT CHAIR SIGNATURE Revised _... _-

22 Request for Laser Privileges University of Virginia Health System Division of : Please check those types of lasers that you are requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: 1 Completed Formal Training 2 Limited Experience - without formal training 3 Extensive Experience - without formal training PRIVILEGES Re uested I l C(. Date Clinician's Signature As Division HeadlQI Liaison and Department Chair, we have review d the above-named clinician's level of experience and past performance as related to re ue ted privileges and ~ree?~tceli~::s qualification_s_a_re_a_p_p_r_op_r_ia_t_e. ~'<::::7L- ~DatJa= &;;:;r;r~ 7 Department Chair Please return completed form to Clinical Staff Office, Box Rev

23 , "...u~~:t1 Illliii HEALTH SYSTEIvI Wv1 Ja. J) u.s'ua. REQUEST FOR CLINICAL PRIVILEGES Department of Obstetrics and Gynecology Fellowship/Post-ResidenC)' Training location and Years cts-98 Boa~ DBI bi v1 YearOf~~~tion SUbspecia~c~fciU Of) to1o~ Y:'f~on Admitting Privileges? ~s 0 No / UVA Outpatient Surgery Center Privileges? u::ryes ONo PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHEREYOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. I. MEDICAL According to category, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake patient management except in emergency. Category B Category C The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, or3 in the EXPERIENCE column. Type 1 Completed Formal Training Program Type 2 Type 3 Limited Experience - without formal training Extensive Experience - without formal training PRIVILEGES REQUESTED GENERAL MEDICINE INFERTILITY AREAS CATEGORY TYPE REQUESTED EXPERIENCE (A, B or C) (1, 2 or 3) J?l1!~en~~I D!!!~.!!?.~.~.~nd...T..rea~I!.!~D!..._ _.....'-_..._ ,--:""._.._._..._.._-_..._..._.._ Disease prevention..._..._,-_..._,..-_.._ ~.-.-._..._ Health maintenance...._...-.._.._..._ ~ _--_..._..... ImmuniZation Non-surgical evaluation and management

24 .. " Subspeci~lty evaluation Endocrinology Oncology tj I' II. PROCEDURES ~ ~ ~ Category A Category B The applicant According to category,.enter A, B or C in the REQUESTED column.,"n."'m~i("'" the procedure except in emergency. ~ ---~ The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in tria everitofanticipated or actual difficulties. CategoryC Type 1 Type 2 Type 3 The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, or 3) in the column. rogram Limited Experience - without formal training Extensive Experience - without formal training Breast Cervical Endometrial

25 INFERTILITY MATERNITY CARE/DELIVERY In vitro fertilization and related procedures Amniocentesis Genetic l=~ri\i I-gI'l Standard FHR monitoring Forceps Low Mid Outlet- Intrapartum care Intermediate risk High risk Routine risk Lacerations repair 1st & 2nd degree 3rd degree 4th degree TransabdominallTranscervical CVS 1st trimester 2nd trimester 3rd trimester Basic Targeted Vacuum

26 SURGICAL D & E: <12 weeks D & E: weeks Injection of abortifacients

27 '. OTHER \

28 ~ Page 6 As Division Head/OJ Liaison and DepartmentChair, we have reviewed the above':"named;'clil1ician's level of experience and past performance as relatedto requested privileges and agree the clinician's qualifications are appropriate. We have reviewed supporting documentation submitted for "other" privileges requested by the clinician and have determined that documentation is adequate to verify competency. We fi~as follows:. ~cceptablereview with recommendation.ofappointmerrt to th~ clinicalstaffwith clinical privileges as requested. D Acceptable with proctoring as documented by the Department Chair andlor Division Head/Ot Liaison

~ ~..._..._...~..._ CLINICIAN SIGNATURE

~ ~..._..._...~..._ CLINICIAN SIGNATURE Clinical Privileges Update Form UNlVEHSrry qrvirginiau Barbara Wilson Department of Dermatology L--. HEALTH SYsTEM ~ ~ I have reviewed the privileges previously granted to me and request the following