Allison Walton, FNP AHP Clinical Privileges Update Form Department of Neurosurgery I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Practitioner's Signature.r=>; As the Supervising Physician/QI LiaisonfDepartment Chairl Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP'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: o Record Review Annual Evaluation ~ Continuing Education Conferences 0 Student Evaluation ~ Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA o yisk Management Events/Quality Management Reports for claims [id'"prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: ~ ~ Acceptable review with recommen. n of reappointment with clinical privileges as requested. o Concerns noted on revie as requested, but subje q\2-~f t;~ ~\t..~\,,~ Aaron Dumont, M.D. Date f Printed Name ~ tj1(()-}j9 orr ave action plan in place with recommendation of reappointment with privileges vfn months. Neal Kassell, M.D. Printed Name John Jane, Sr., M.D, Printed Name Date Alternate Supervising Physician Signature Printed Name ~ Date t,,\ Il0'\ cs Administrator (for Me employees) Printed Name Mark E. Shaffrey, M.D., Chair irector Signature (for HSFemployees) Printed Name revised3/1/2005

AHP Clinical Privileges Update Form I have reviewed the privileges previously granted (copy attached) to me and request t New Privileges to be Added (please indicate category level and type of experience): I Current Privileges not to be renewed: * *Privileges 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. pri i1egesare 0 be repo d as voluntarily relinquished you will be notified and recei e a copy the report to be filed with the National cf' r Dat k. Practitioner's Signature As the Supervising PhysicianlQI LiaisonlDepartment Chairl Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualiflcations are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~... Record Review Annual Evaluation ff )Zontinuing Education Conferences 0 Student Evaluation ~Yhysical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA (g'"...-riskmanagement Events/Quality Management Reports for claims 0' Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ----------------------------------------------------------------------------------- We find as follows: ~cceptable review with recommendation of reappoi ace with recommendation of reappointment with privileges ~ D~te ' l{ji%.\0'" Printed Name -:Id""D ~":S('. ~ Printed Name \ I ~1>~~ Printed Name I l Date Alternate Supervising Physician Signature Printed Name Date Administrator (for Me employees) ~ Printed Name ) I revised 3/1/2005

,",-.1..1..1. 'L-UIU'-41 J: IIYIU::g,\;:s uljuatt: rorm _A_t =---ll.s=-::..()_h.--,--uj-=---~-----,f._o_n..l--_department of --+--l-'o~--'-=.;~=---.::..::l~:---v::=---- I have reviewed the privileges previously granted (copy attached) to me and qu the following changes: New Privileges to be Added (please indicate category level and type of experience):,.---" Current Privileges not to be renewed: * *Privileges 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 pro eding. If privileges are to be reported as voluntarily relinquished you will be notified and recei e a co y of the report to be filed with the N ti Practi ner a bank. Date As the Supervising Physician/QI Liaison/Department Chairl Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP'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: ~ j Record Review Annual Evaluation ~ ~ontinuing Education Conferences 0 Student Evaluation Q/-Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA g...-riskmanagement Events/Quality Management Reports for claims Ii2" Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other ------------------------------------------~--------------------------------------- We find as follows: ~ Acceptable review with recommen o Concerns noted on revie as requested, but subject Date' of reappointment with clinical privileges as requested. i 2.-\ '->. \ C)Sive action plan in place with recommendation of reappointment with privileges n months. sing Physician Signature ~~ \.".to..z~\\ kab. Printed Name I Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physlcian Signature Printed Name Date Service Cntr A Printed Name D'ate" Chair/ anal AI ::JC) Y\f\..f\ "3:;'~~...5r re ( r HSFemployees) Printed Name I ~"JR/VJ \'&th ~faf{ C(C<. ~ revised 1/8/2003 \

Privilege List for Family Nurse Practitioner 23-Feb-05 Name: A t.,.l-f.sch Date: 1:11:~f cr5 PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WIDCH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A The applicant will not undertake patient management except in emergency. B The applicant will manage patients with physician present. C The applicant will manage patients in collaboration and/or consultation with the physician. ->">, ~, Anesthesia Regional Pulmonary Function Testss EMG Audiometry Tonometry Slit Lamp Exam Spirometry Percutaneous PAP Smear Fetal Monitoring IncisionlDrainage Skin Laceration Anoscopy Sigmoidoscopy EMG Biofeedback Arthrocen tesis Arterial Blood Gas Bone Marrow Paracentesis Thoracentesis CPR Endotracheal Circumcision Skin Testing of Abscesses Repair Aspiration Intubation Norplant Insertion & Removal Breath Hydrogen Test Cryotherapy Lumbar Puncture Foreign Body Removal - Subcutaneous / Foreign Body Removal - Subungual Congenital Heart Disease Rheumatic Heart Disease GI Disease Dif Dx & Tx Premature Disorders Dx & Tx Premie Growth & Development Neurological CNS Infections Psychophysiologic Renal Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Electrolyte & Water Balance Croup, epiglottitis. Neonatal Ped Adol Adult Geriatric c. c. < <, c c c c. t. e, C, <: c. r. C,, A A A A A A A A c, '- c, t ~ ~ <: ( t {' ~ ~ e ~ C C I' ( l <: ( c. c, <:. t ~ c. Co e, c ~ ~ C!. c e, <:. c Q ~ Q. (I t ( ~ Page 1 of 5

,~,~ ~, Cystic fibrosis Pulmonary Dif Dx & Tx Pre & Post Op Cardiac Attention Cerebral Care Deficit Disabilities Palsy Head & Spinal Cord Injury Ped Learning & language disabilities Ped Mental retardation Pituitary Conditions Malabsorption Immunization Osteoarthritis Rheumatoid Rheumatic Cardiac Peds Dif Dx & Tx Arthritis Fever - Acute Rehab Neurodegenerative Endocrine/Metabolic Disorders Dif Dx & Tx. Med Dif Dx & Tx Allergy/Immun Die Dx & Tx Arthritis Cardiovascular Birth Defects Eval Newborn DifDx & Tx Newborn Adjustment Ped Behavioral Cognitive Dialysis screening Dif Dx & Tx Problems Rehab Mgt Rheumatologic/Vasc HIV,AIDS Immunodeficiency Health Geriatric Cholecystitis Pancreatitis Cirrhosis Maintenance Problems Dif Dx & Tx Dif Dx & Tx Hepatic Diseases Dif Dx & Tx Gynecologic Routine Dif Dx & Tx Infertility Initial Eval & Mgt Sexual Counseling Infectious Disease Dif Dx & Tx Diabetes Mellitus Fractures & Dislocations Pediatric Emotional Disorders Dermatologic Diseases - Dx & Tx Drug Reaction & Overdose CVA Rehab Anesthesia Local Foreign Body Removal - External auditory Foreign Body Removal - Vagina Wound Mgt Assess for Functional Integrity Pulmonary Artery Catheter Manipulation Wound Mgt- Wound preparation Wound Mgt- Debridement Wound Mgt. Closure Wound Mgt Dressing Wound Mgt. Immobilization Neonatal, Ped Adol Adult Geriatric t ~ c ~ Q ~ ~ ~ ~ c ~ ~ t. e, 0.- e, e. <:. c. ~ Co c, <:. c c ~ ~ ~ Co ~ c ~ c. '- ( ~ C c: c. Q ( <!. Q ~ ~ <:. c. e ~ c: ~ ~ c ~ c, ~ C c Q \:. c c Q ~ ~ o C c: <!.. C c:: ~ ( "- ~ <: c ~ c (' ~ Q c t e. C c <:. e ~ ~ C (' c. ~ <: C' c ~ e Q C C C C' c C' c C ~ ~ o c <' Q C < C <: <!. c (. Q. c. 0 r c e <: < c ~ c c, (' (' C' c ~ (' C Q c c e, r C c: r c C c o C!. <:. Q t Co C. c c c (' c e c c \ c c c (' c C c C Page 2 of 5

_~. '-~'. Nail Avulsion IUD Insertion & Removal Pessary Insertion & Removal Allergen Histamine Immunotherapy Provocation Wound Mgt. Removal Prenatal Counseling Impotence. Evaluation & Mgt Pain Management History and Physical Ox, Assessment & Mgt Telephone Triage/Consultation Hospital Rounds of Sutures/Staples Admissions (with MD collaboration) Order- Labs Order- Urodynamic Studies Order - ECG Order Echocardiogram Order- Holter Monitoring Order- EEG Order Order Order Radiographs Consults Medications Nutritional Status- Eval & Mgt Peripheral Central Venous Line Placement Contraceptive Counseling Health Maintenance & Disease Prevention Cerumen Impaction Removal Ventilator Weaning Mgt Chemotherapy- Intradermal POIIVlIntrathecal Skin Testing Lab Test- Dipstick Urinalysis Lab Test - Cervical Cultures Lab Test- Urethral Cultures Lab Test - Rectal Cultures Lab Test- Throat Cultures Lab Test Soft Tissue Site Cultures Lab Test- Blood Cultures- Draw Surgical Assist Surgical Drain Removal Tracheostomy Tubes Remove Transtracheal Aspiration Wound Mgt Electrocoagulation OB Routine Prenatal & Postpart Eval & Mgt OB. Intermed. Risk Prenatal & Postpart Eval & Mgt OB High Risk Prenatal & Postpart Eval & Mgt 'cardiac Arrest- Assist Colposcopy. Cervical BiopsylECC Condyloma Tx's Microscope Eval- Urine Microscope Eval Post Coital Cervical Mucous Microscope Eval Breast Discharge Microscope Eval Amniotic Fluid Intermittent Catheterization Tx Ultrasound Fetal Ltd Fetal Presentation Ultrasound. Fetal Ltd Fetal Cardiac Activity Ultrasound - Fetal Ltd > Dating 1st Trimester Ultrasound. Fetal Ltd AFI Neonatal < Ped Adol Adult Geriatric (' c. c c c c. ~ c C' (\ ~ ~ c. (' ('" (' (' <: ~ c ~(' c C c c. (. c. ~ c. c Q c c c c ('" c C ~ c c (' C' c c c ~ 0 ~ C (' Q C C <: ~ c C. c, C c:. ~ c c (' c C'. o c <:. (' c c c c o c o ~ 0 (I o C r C- eo <!. (' C c c. c c t' c ~ <:: c c C' (' c.. c " <: ~ C o ( <:. C < c A A A A c, c c. ~ c, \.. e. < Page 3 of 5

Neonatal Ped Adol Adult Geriatric.~ Urodynamic Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Percutaneous EMG Gouty Arthritis,. rcp Adjust Treatment Protocols Heme/One Dif Dx & Tx Hyperbilirubinemia Spinal Shock - Mgt Thrombophlebitis Urologic Urticaria Disease - Dif Dx & Tx Adjust Pacemaker Settings Adjust Cardiac Assist Devices Ambulatory Camino Halux 02 Saturation Bolt Removal Hansel Smear - Nasal Secretions Intracardiac Catheter Removal Omaya Reservoir TPN Ordering Typanometry Ventricular Catheter Removal Conscious Diaphragm Sedation Fitting Biopsy - Endometrial Chest Tubes - Clamp and/or Remove Epicardial Pacing Wire Removal Doppler Monitoring of Fetus Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Clavicle Ortho s - Upper Extremities Ortho s - Lower Extremities Pulmonary Artery Catheter removal Biopsy/Removal Biopsy - Vulvar - Skin Lesion Foreign Body Removal - Nasal Lab Test - Vaginal Cultures Serum Sickness Microscope Eval - Vaginal Secretions Authorized Evaluate Evaluate Evaluate to Prescribe - ECG - Echocardiogram - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate - Urodynamic Studies Dermatomyositis Nephrotic Disease Dif Dx & Tx c.. <:. c. < c o (' c o ~ c ~ ~ ~ <:. c. c C ~ ( c, c. c. c c. c c. " C r C C c. r c ~ c <: ~ o c c c C c C c c C'_ c. c e L c. ~ ~ c. e, C. \ c c. (' c c, C- (' C. C C. c, c c. c. c. c c. c C- e. c. C C- c <: c C. e r C t e. e. C c. r Page 4 of 5

OTHER PIUVILEGES Neonatal Ped Adol Adult Geriatric ~(~05~ _ DATE LlliJ-----'-QJb,,-----,o--_A_L-L---=-/~ --,-'"_VJ. _lrk_lt_orj Signature Name Printed As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named pracf on rs qualifications are appropriate. n1a'z-~105 ~l '2..crl ()S DATE Name Printed DATE Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Dept Chair or Svc Center Administrator Name Printed Page 5 of 5