TEMPLATE FOR REQUEST FOR WAIVER FOR TNS CE HOURS

TNS Name __________________________

Address __________________________

__________________________

__________________________

Phone __________________________

TNS ID Number ____________________

This is to request a waiver of the Trauma Nurse Specialist (TNS) continuing medical education requirement as specified in the Illinois EMS and Trauma Center Code Section 515.750 f) 3) C ), “Documentation of any 40 hours of continuing education every two years . . .” The hardship in meeting this requirement is that it restricts the time frame for obtaining the appropriate CE in the 4 year licensure period and might prevent me from obtaining a TNS certification renewal. The standard of care would not be reduced as I will obtain a total of 80 hours of CEU in my four year license period which ends ________________(date).

___ I work in a hospital as a Trauma Nurse Specialist and have obtained the signature of the Trauma Medical Director below or the EMS System Medical Director.

__________________________________________

(MD Signature) (Date)

___I do not work in an Illinois hospital or out-of-state hospital that is designated as an Illinois Trauma Center or EMS System Resource Hospital. Therefore I cannot obtain the signature of an EMS Medical Director or Trauma Medical Director.

___________________________________________

(TNS Signature) (Date)