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AHP Clinical Privileges Update.Form -"Da'IJi~l~~(jttipger Department of NICU r'av~'r~;vlewe&'~~epfivilegespreviouslygranted (copy attached) to me and request the following changes:.nc\v'privilaaes{obe A:dded(please indicate category level and type ofexperienee): *~li'v,j/e~~sttott~,ii~we!j~!;e.twtrfp(irted~sl>el~gvqlp,~tiariwt;.ejinqlii~hedunle$~thi~ is done. w~i1eyouare under investigation ; or, in refuriitor n'qtcooductijlg'all investigation or proceeding. If'Ptjyileg.e~ ate t()be reported as voluntarily relinquished you will be notified and..r:~~eixe\l~!ipl'of*lterep~:rt.to,:b~ filed wit~.tj:te. NationatPra;ctitil).jt.er Datailank.,>~,~~,~{, fos.~l, '. " f.),'~;~f:;j<;~;,,:.:"..:~.:,')}:,,":' '..~ractitionetls Sigl1atutc..,~ A$i M':~Wje~~~~i;f;bysj~ian/QILiajSonlJ)epa.riineot Cbairfl\fedi~al:llirecto;l. Service 'Center..AdmJitistrator, we have.,r~vie~e;(ft.q; ~W";!;IJe~'I\Jl~'$;lev~1 Of,ewerj~nc.e,pas~perforJllllnc~aRdquality indiclltors (if renewing privileges) as r _'"relafed t&,r '_< st~d'p.r~vjleges anda.gree 'that the above named AUJ>'s.quaUf'jcatioos'are appropriate. Since thedate of'fhe'fast appqiot;pi Q~~/~e'b~ ef~;yjew.ed appj.icableill.f9rmation fromthcf{)llowiitg s~urces ofqualityanduti\iilation data:. <: J~"1k-_~,~>..:::':'; ~; o o """ Annual Evaluation Studl'mtEvaluation AnnualReview by Dept. Chait orsca,-.,'. W~.'filt~;~s.foU~wSJ:<. ',~~c~~~ictt>le're~iti~ ": ',' " ",c_,_,', ",' _\_,.. ",..., " _"..,~... -,':.' ~jth;c~c~irl';:"ij:hdalio.n,of :re3~p6il"):tment wuh linic~u,prjvilege$,.. -.' c.: '" _.. ---",..., '" ;",".. -, -.' " -- - _ -.. ",...,.. --..,- _ as requested. - Robert Boyle. M.D. Printed Name.John Kattwinkel. M.D. Prinb~dName C,,:_:. ~1.Z:J1CJ. David Kaufman. M.D.. Printed NalTle ::I)~t~.' (l~j IJ Karen Fairchild,M.D. Pri ntedname 'Dafe 7/Jbj)j 'Oate Date. Lorna Fa,cteau. DNS.RN. Chief of Nursing./ Printed Name Chair/RPC Director Signature (for HSFemployees) Printed Name. revised 3/1/2005

AHP Clinical Privileges Update Form _~ Y)_(_d_-=O=-. _U-_C--.::fL~~ Department Of_-+jJ--.::-"'-'/"--C=-..::.~ _ ~ have reviewed the privilege reviously granted (copy attached) to me and request the following changes: ~~ew 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 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 As the Supervising Physician/QI LiaisonJDepartment Chair/ 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 ~ppointment, we have reviewed applicable information from the following sources of quality and utilization data: o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Record Review o Continuing Education Conferences D Physical & Mental Health related to Job Performance D Risk Management Events/Quality Management Reports for claims D Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Ofuer ~ _ We find as follows: '&t> Acceptable review with recommendation of reappointment with clinical privileges as requested. I D Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges e, -i;;r~;ested, but subl 0 a r:j in --\ m::. L- ~~~f 0)( e.v;s;n y ;c;an S;gatu," t\~i\d< LDatG ~ Date ~-,~ I :J.g I 08 Date Printed ~~.~ Printed Name Name Date Chair/RPC Director Signature (for HSFemployees) Printed Name revised 3/1/2005

~lek.o AHP Clinical Privileges Update For.m Department of_-,! ~:.-...!/~c»'~~-=.-j==------ ~-l have reviewed the privileges pr iously granted (copy attached) to me and request the following changes: 3ew 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 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, As the Supervising Physician!QI LiaisonlDepartment Chair/ 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: ~ ~/ Record Review Annual Evaluation [i2f... Continuing Education Conferences 0 Student Evaluation ~Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA G1'jRisk Management Events/Quality Management Reports for claims [Q' Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: f Acceptable review with recommendation of reappointment with clinical privileges as requested. o ~()\c.e-;t Printed Name 'b\9y_\ e, T jo~j.j tai-(w,1-/ ((t:.-( Printed me, D'itE! ---1 {\2\ '0", Date PrintE!d NcIr1e l e.ll l1jc~ Printed Name A]J Printed Name ~ ' ''\,ivu~ ~ I {CV'l.!V\. ~ reoi~ed 3/1;'2995

,. -r=>: Privilege List for: Neonatal Nurse Practitioner 27-Jun-05 Name: Date: 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 WHICH 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. ~~edical Iedical ~rocedure. rocedure Arterial CPR cannulation Intubation & Mechanical Ventilation Circumcision Lumbar Peritoneal ECMO Puncture dialysis Premature Disorders Dx & Tx Premie Growth & Development Neonatal Intensive Die Dx & Tx Birth Defects Eval Intubation & Mechanical Ventilation Neonate Sepsis History and Physical Dx, Assessment & Mgt Telephone Triage/Consultation Hospital Rounds Patient Education Admissions (with MD collaboration) Order Order Order Order Order Order Order - Labs - ECG - Echocardiogram -EEG - Radiographs Consults Medications NICU - Pre/Post Op Mgt NICU - Sedation & Pain Control Ventilator Weaning Mgt Nutritional Exchange Status. Eval & Mgt Transfusion Peripheral Central Venous Line Placement Mickey. Gastrostomy Neonatal Resuscitation Pacemaker Insertion- Assist PEG Placement- Assist Buttons - Changing PH Probe > Insertion & Verification of Placement Sedation TPN Ordering Umbilical Catheter - Arterial or Venous Neonatal Ped Adol Adult Geriatric r- C L N\(\ r./ C- c, c, r c. C c C c c, o, c. C (' r (" r: c, L- (... c, (' C- L c c, ~. L c. ~\{; >.1/.(\ ~l(\ r C C Page 1 of 2

Cardiac Care - Pre & Post Op Cardiovascular Dif Dx & Tx,------- Congenital Heart Disease.vledical Hyperbilirubinemia Immunization Prenatal Counseling Chest Tubes - Clamp and/or Remove Newborn screening Chest Tubes - Insertion & Mgt Authorized to Prescribe Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Evaluate - Labs Evaluate - Radiographs OTHER PRIVILEGES Neonatal, Ped Adol Adult Geriatric C C c. c. c. c. C. G C_ r. c. c c. c, V ------- DATE 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 practitioners qualifications are appropriate. DATE ~( 2-C[ ( -s: OA-IJ K.A-- Name Printed DATE DATE q, I~\ ID ~ DATE -j ~b 16(; DATE uc<-k g- (w (Or- <).(2.0)- ql4l~ Dept Chair 'or. Svc enter Administrator Name Printed v.p~ \ Page 2 of 2