Emergency Preparedness

Appendix Q.1

Kern Medical Emergency / Disaster Temporary Privileges / Status Request Form

In the case of an emergency, any licensed practitioner who has been granted clinical privileges and/or status is permitted to do everything possible within the scope of his/her license and scope of hospital protocol, to save a patient’s life or to save a patient from serious harm, regardless of staff status or privileges granted. The purpose of this form is to ensure that the individual requesting emergency / disaster privileges or status is qualified and licensed to provide care. PERSONAL DATA Last name: _____________ First name: _____________ Middle: ________________ Date of Birth: ___________ Social Security #: _______________ Gender: Male _____ Female _____ Address: _______________________________________ City: _______________ State: ________ Zip code: ________ Telephone #: ( ) ___________ Cellular: ( ) _______________

Type of License / Certification: _______________License / Certification #: __________ State of issue: __________ Expiration date: ________________ Federal DEA # (if applicable): _______________

PRIMARY HOSPITAL AFFILIATION

Institution: _____________________

Dates of employment: _____ / _____ State: _____ Zip code: ____

Address: ______________________ City: __________

Title / Position: _____________________ Department: ______________ Supervisor: _______________ Telephone #: ( ) _______________

EDUCATIONAL DATA

Institution: __________________

Dates of attendance: ______/_____ State: _____ Zip code: ___

Address: ____________________ City: __________

Degree: _____________________

PROFESSIONAL LABILITY Current Insurance Carrier: ________________________________

Policy #: _________________________ Address: ________________________ City: _____________ State: ____ Zip code: _______ Coverage limits: _____________

Dates of coverage: ______/______

May 2008

Incident Command System Training

Page 35