BASIC TRAUMA LIFE SUPPORT by HC120911041629

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									      INTERNATIONAL TRAUMA LIFE SUPPORT

                  POLICY AND PROCEDURE
                             Table of Contents


I.    POLICY AND PROCEDURE MANUAL

      A. INTRODUCTION                                           page 2


      B. GENERAL POLICIES AND PROCEDURES                        page 2


              Section 100 – Course Requirements                 pages 2-4


              Section 200 – Course Fees                         page 4


              Section 300 – Chapter Committee                   page 5


              Section 400 – Classifications                     pages 6-11


              Section 500 – Non-Discrimination and Harassment   pages 11-12


              Section 600 – Dispute Resolution                  pages 12-13


              Section 700 – Regional Coordinator                pages 13-14


              Section 800 – Executive Committee and Sessions    page 14


      C. RECORD OF CHAPTER OFFICIALS                            page 15


II.   SAMPLE FORMS                                              pages 16-38




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               INTERNATIONAL TRAUMA LIFE SUPPORT
                        Kentucky Chapter
                                   Revised September 2011

                             POLICY AND PROCEDURE MANUAL

A. INTRODUCTION

Kentucky ITLS is chartered as a chapter of International Trauma Life Support (ITLS). Dr. John
Campbell is the well known founder and author of ITLS.

This dedicated group of emergency physicians, nurses, paramedics and EMT's recognized the
influence ITLS training had made in improving the care of the severely injured trauma patient and
aspired to spread this knowledge through the world.

The Policy and Procedure Manual of ITLS Kentucky will be evaluated at least every 4 years or sooner
if deemed necessary by the Steering Committee. The ITLS KENTUCKY STEERING COMMITTEE
must approve any modifications. Each steering committee member will receive a copy of the Policy
and Procedure Manual annually or when modifications are made to the document.

This policy manual is meant to accompany the ITLS Instructor Manual. In addition to the national
guidelines described in the instructor manual, this policy manual will attempt to:

         Outline the structure of ITLS on a state level
         Clarify the various levels of certification
         Describe the administrative tasks required to hold an approved Provider or Instructor Course
         Provide the necessary forms to execute a complete course and communicate routine
          administrative duties to the KY ITLS office.
Successful completion of ITLS does not imply that an individual is physically or legally capable of
performing procedures or skills that he is otherwise not approved to use by the State, his/her Medical
Director, or other certifying licensing bodies.


B. GENERAL POLICIES AND PROCEDURES

Section 100 – Course Requirements

.01       International Trauma Life Support courses must follow the nationally/internationally accepted
          guidelines for trauma care as outlined in the following reference materials:

              ITLS Provider Manual – 7th edition
              ITLS Instructor Guide – 7th edition
              ITLS Military Provider Manual – 1st edition


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           Pediatric Trauma Life Support Provider Manual – 3rd edition
                                                              rd
           Pediatric Trauma Life Support Instructor Guide – 3 edition
                                             nd
           ITLS Access Provider Manual – 2 edition

.02   Recertification courses may be conducted in conjunction with provider courses or as
      determined by the course coordinator, whereby, minimum requirements established by
      KENTUCKY ITLS must be successfully completed.

.03   Courses will be conducted in an organized professional manner that reflects positively on the
      chapter.

.04   Confidentiality with respect to student performance shall be maintained at all times.

.05   All courses must be requested using the ITLS Course Management System (CMS) online.

.06   Requests for the approval of courses shall be received no later than 30 days prior to the
      course date.

      If, for any reason, the course request is not received in a timely manner, the Chapter
      Coordinator will determine course approval or denial.

.07   All requests for approval of courses shall contain the course dates, location, course medical
      director, course coordinator, list of instructors, list of Affiliate Faculty and course schedule.
      Course approvals will be reviewed by the Chapter Coordinator.

.08   To assure the quality control of a course, every course must have a Medical Director, who is
      available by phone or pager. One Affiliate Faculty member must be on site at all times. The
      Affiliate Faculty member may concurrently serve as an instructor and/or coordinator at the
      course. The Steering Committee reserves the right to require additional Affiliate Faculty. The
      Steering Committee reserves the right to modify this requirement based upon individual
      request.

.09   The Chapter Coordinator will receive a complete copy of all course paperwork from the CMS
      website before the course is conducted and must receive the remaining paperwork within 30
      days after the course is completed. The Course Coordinator will send the following paperwork
      to the Chapter Coordinator upon completion of the course:

           ITLS Post Course Checklist
           Student Course Evaluation Sheets
           Affiliate Faculty Course Evaluation Sheet

.10   ITLS provider courses may be held over a series of dates, as outlined in the instructor manual.
      Any schedule not following the instructor manual must be submitted to the Steering
      Committee with the following restrictions:

           Upon submission of the course approval form any expanded agenda must be included
           The entire course must be completed within a 15 day calendar period
           All testing must be held on the same day
           All core materials outlined in the ITLS books must be included in all approved courses.
            Additional content may be added to expand the scope to fit local needs.
           Any proposed didactic additions or subtractions must be submitted to the ITLS
            Steering Committee for approval 30 days prior to the course offering.


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           Any late changes in course content may result in removal of course approval and non-
            delivery of cards.

.11   Upon receipt of a complete course request on the CMS website, it will be reviewed for
      adherence to guidelines (submitted 30 dates prior to class, all information entered correctly,
      etc.). The website will assign a course number to the class. If the course is approved all future
      rosters and correspondence regarding this course should include this number.

.12   If a course is rejected for deficiencies, the course coordinator will be notified and given an
      opportunity to correct and resubmit the course request.

.13   If a coordinator or medical director is delinquent in providing required course paperwork and
      fees as stated in this policy manual, they may be denied approval to schedule another course
      until these requirements are met.

.14   Courses are subject to periodic and possibly unannounced monitoring by an Affiliate Faculty
      or Steering Committee Members to ensure compliance with state and international policies.

Section 200 – Course Fees

.01   Course coordinators may charge a reasonable fee to students as necessary to cover costs of
      conducting the course, instructor honorariums, course materials and chapter and international
      student certification fees.

.02   The following fee schedule shall apply for international and Chapter fees:

        International -      $10.00 per student attending or enrolled
                             (There are no International fees for Instructor Recertifications.)

        Chapter -     $15.00 per Student attending or enrolled

.03   Chapter fees for students certified may only be changed upon approval by the Steering
      Committee.

.04   International fees for students are established by the International ITLS Board of Directors.

.05   International and Chapter fees for students attending or enrolled are to be paid when
      completed course rosters and post-course paperwork are submitted to the Chapter Office.

.06   The ITLS Course Management System (CMS) will not be accessible for Course Coordinators
      to access and print their own cards unless fees are paid or the Course Coordinator’s
      organization/agency has a payment history qualifying that debt will be paid.

.07   The Chapter Coordinator reserves the right to deny course approval based on outstanding or
      bad debts incurred by a particular agency or individual that pertains to ITLS Kentucky.

.08   Service fees or administrative costs may be charged for checks/payment terms returned due
      to insufficient funds.

.09   Administrative cost for canceled registration at a course may be recovered by the organizing
      agency.


Section 300 – Chapter Steering Committee


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.01   The ITLS Chapter Steering Committee shall operate in accordance with the bylaws of the
      organization or at the direction of the Chapter charter holder.

.02   The Chapter Medical Director is the chairperson of the Chapter Steering Committee and
      conducts all business meetings. He/she has the authority to approve and disapprove courses;
      and carry out all other duties specified in the chapter bylaws and shall work in conjunction with
      the Regional Coordinators as per Section 300.

.03   The Chapter Coordinator is responsible for coordinating activities of the regional coordinators,
      affiliate faculty and state committee members.

.04   The ITLS Chapter Steering Committee will select individuals to represent the organization at
      the ITLS International Conference.

.05   Chapter Steering Committee members with the exception of the Chapter Medical Director,
      Chapter Coordinator, and the Chapter Executive Secretary are appointed for a 3 year term.

.06   The Chapter Steering Committee is setup to provide representation for all areas of Kentucky.
      Vacancies will be filled with individual representative of the geographic area in which the
      vacancy occurs.

.07   Positions on the Chapter Steering Committee will be filled from applicants who have submitted
      a letter of intent along with a resume and two letters of recommendation from Affiliate Faculty.

.08   Steering Committee members are required to attend 3 out of 4 meetings each year during the
      committee appointment and be actively participating in ITLS in their region.

.09   Duties and responsibilities of Chapter Steering Committee members include advising the
      Chapter Medical Director and Chapter Coordinator on matters concerning the Chapter ITLS
      Program on issues such as:
          Development of chapter policy and procedures

          Promulgation of ITLS throughout the Chapter area

          Develop long range and strategic plans

          Dissemination of information at the local level

          Disciplinary issues

          Provide mechanism through which personnel throughout the area have a voice in ITLS
           related matters

          Appoint affiliate faculty in conjunction with the Chapter Medical Director and Chapter
           Coordinator

          Oversee the due process of revocation for ITLS instructors, affiliate faculty, course
           coordinators, and course medical directors

.10   The Chapter Steering Committee can remove a Chapter Committee Member should the need
      arise. Written allegations shall be submitted to the steering committee. The committee
      member may be suspended pending investigation.




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.11    The Chapter Steering Committee Chairman shall appoint a 3-member investigation team.
       The investigation shall be completed within 60 days and their findings presented to the
       Steering Committee.

.12    The committee member will be informed in writing, of the basis of the allegations and given an
       opportunity to refute the allegations, in writing, within 30 days.



Section 400 – Classifications

.01    Provider (Basic) – Must be an entry-level EMS provider such as:
           First Responder

           Emergency Medical Technician- Basic

           Licensed Practical Nurse

           Medical Student, Physician Assistant Student or RN Student
       with suitable qualifications who functions within their scope of practice. Upon completion of the
       Basic Provider course with a written test score of at least 74 percent and at least an
       “adequate” rating on the patient assessment skills test, the student will be certified for a period
       of 3 years.

.02    Provider (Advanced) – Must be an advanced-level practitioner who can perform advanced
       procedures such as:
           Paramedic

           Registered Nurse

           Physician Assistant

           Physician

           Other Allied Health Professional who holds suitable qualifications
       who is certified or licensed and who functions within their scope of practice. Upon completion
       of the Advanced Provider course with a written test score of at least 74 percent and at least an
       “adequate” rating on the patient assessment skills test, the student will be certified for a period
       of 3 years.

.03    Provider (Pediatric) This course is not currently available in Kentucky.

.04    Provider (Access) This course is not currently available in Kentucky.

.05    Provider Re-Cert- All current Advanced and Basic providers must attend a one-day ITLS
       recertification course prior to the expiration date on their card or complete a two-day ITLS
       Advanced or Basic Provider course. KY ITLS will accept current certification cards from any
       other state to apply for admittance into an approved provider course. The dates of certification
       of the out-of-state card will apply.

.06    Instructor Candidate – Must be a student who has successfully passed an ITLS Basic,
       Advanced, or Pediatric ITLS provider course with a written score of 90 percent or better; a


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      rating of “excellent” on the patient assessment skills test; and an "instructor potential"
      recommendation by an affiliate faculty member or course coordinator during the ITLS provider
      course. The candidate must have two years of experience in their career level.

      A physician who is board certified in Emergency Medicine and/or ATLS certified may become
      an ITLS Instructor without taking an ITLS Provider Course though they must still attend an
      ITLS Instructor Course. With proper documentation ITLS Instructor Candidates from other
      states may become a KY ITLS Instructor by attending a KY ITLS Instructor Course and
      bypass the provider course.

.07   Instructor – After meeting all Instructor Candidate requirements, a student who has
      successfully completed an instructor course and has been monitored (in lecture, skills station,
      and patient assessment at a provider course) by an affiliate faculty member, will be certified
      for a period of 3 years. Basic Providers may instruct only Basic-level courses.

      Written allegations of inappropriate conduct by or inadequate knowledge base of an instructor
      shall be sent to the KY ITLS Steering Committee. The KY Steering Committee may initiate an
      investigation and may also suspend the instructor’s certification status pending the outcome of
      the investigation. Upon completion of the investigation the instructor will be informed, in
      writing, of the basis of the allegation and given an opportunity to refute the allegations within
      30 days in writing. Final disciplinary action may include, but is not limited to one or more of the
      following:
          Temporary suspension of instructor certification for a specified period of time

          Permanent suspension of instructor certification

          Remedial training

          Supervision by an Affiliate Faculty for a specified period of time

.08   Instructor Re-Cert – All current instructors must teach at least three ITLS courses (instructor
      or provider) within the three years of certification and attend an Instructor Update or
      Refresher Course as determined by the Chapter. Instructors who do not participate in the
      required number of courses in the given time frame may complete an instructor course within
      6 months of the expiration date on their instructor card to remain an instructor. They will not
      be required to be re-monitored.

      Instructor updates may be required as deemed necessary by the Steering Committee.

.09   Bridge Certifications – A PHTLS or ATLS instructor may become an ITLS instructor
      following successful completion of an ITLS provider course. The Instructor must then apply to
      the Chapter Coordinator requesting reciprocity. The Instructor must also provide any past
      activities regarding PHTLS instruction and a letter confirming good standing from their former
      Chapter Coordinator. After completion, the Chapter’s policies for provisional instructors will
      apply and must include monitoring.

      A PHTLS provider may become an ITLS provider by taking and passing an ITLS provider
      course.

.10   Course Coordinator – Must be an experienced EMS educator and program organizer with a
      thorough knowledge of the ITLS program and a demonstrated history of coordinating and
      conducting multiple session programs. ITLS certification required. Responsible for
      coordinating all aspects of the ITLS course, from pre-course to post-course; submits required


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      course completion paperwork within 30 days of completion of the course; ordering textbooks
      and preparing student and faculty course packets; arranging equipment and setting up
      skill/test stations and on-site coordination; oversees patient assessment practice and testing
      stations; grades written exams; being present through all courses coordinated to serve as
      primary resource for information and questions of an administrative nature; and serving as a
      liaison between providers and the course medical director, affiliate faculty, and Chapter office;
      makes instructor assignments; and distributes course completion cards and certificates.

      If written allegations are made regarding inappropriate conduct by or an inadequate
      knowledge base of the Course Coordinator, the Chapter Steering Committee may initiate an
      investigation. The Course Coordinator’s designation may also be suspended pending the
      outcome of the investigation. The Chairperson of the Chapter Steering Committee shall
      appoint a three member special committee to conduct the investigation. The Investigation
      shall be completed within sixty (60) days. Upon completion, the Course Coordinator will be
      informed, in writing, of the basis of the allegations and given an opportunity to refute the
      allegations, in writing, with in thirty (30) days. The special committee will then make
      recommendations for action including, but not limited to one or more of the following:

           Temporary suspension of the Course Coordinator designation for a specified period of
            time
           Permanent suspension of Course Coordinator designation
           Remedial training
           Supervision by the Chapter Medical Director and/or Chapter Coordinator

.11   Affiliate Faculty – Must be a current ITLS instructor who possesses considerable knowledge
      with respect to the Chapter structure and operations, and who is willing to maintain
      involvement with the growth and development of the ITLS program and educational materials.
      They must complete a Chapter ITLS Steering Committee approved Affiliate Faculty Training
      Program. Affiliate Faculty monitor the quality of ITLS courses in the chapter, serve as a
      resource for course coordinators and medical directors, and monitor new ITLS instructors and
      instructors from other states wishing KY Instructor status. In addition they participate as
      faculty for instructor courses and updates, participate as faculty for provider courses,
      participate in the ITLS Steering Committee structure, serve as the primary liaison between
      ITLS instructors and the ITLS Steering Committee, disseminate information to providers and
      instructors, promote ITLS and provide valuable input affecting decisions made at the chapter
      level.

      Anyone interested in becoming an Affiliate Faculty must complete and submit an Affiliate
      Faculty application along with a curriculum vitae, letters of recommendation by 2 current AF
      and letter stating intent to the Steering Committee. The Steering Committee shall vote on the
      appropriateness of application and by majority vote said status will be granted or denied. If
      granted the applicant will be given Provisional Affiliate Faculty status and will be upgraded to
      Affiliate Faculty after successfully being monitored while performing the role of an Affiliate
      Faculty by an experienced Affiliate Faculty.

      Appointment is for 3 years and to be reappointed an Affiliate Faculty must teach three classes
      in the 3 year period and be active in the other roles of the position.

      If written allegations are made regarding inappropriate conduct by or an inadequate
      knowledge base of the Affiliate Faculty, the Chapter Steering Committee may initiate an
      investigation. The Affiliate Faculty’s designation may also be suspended pending the outcome
      of the investigation. The Chairperson of the Chapter Steering Committee shall appoint a three
      member special committee to conduct the investigation. The Investigation shall be completed
      within sixty (60) days. Upon completion, the Affiliate Faculty will be informed, in writing, of the


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      basis of the allegations and given an opportunity to refute the allegations, in writing, with in
      thirty (30) days. The special committee with then make recommendations for action including,
      but not limited to one or more of the following:

             Temporary suspension of the Affiliate Faculty designation for a specified period of time
             Permanent suspension of Affiliate Faculty designation
             Remedial training
             Supervision by the Chapter Medical Director and/or Chapter Coordinator


.12   Course Medical Director – Must be a licensed physician within Chapter boundaries and
      should be familiar with EMS systems and prehospital care and have experience and training
      related to trauma patients. The Course Medical Director should be an ITLS instructor or
      should have served as co-director for one course with a physician ITLS instructor. The Course
      Medical Director provides clinical oversight during the course and must be on-call and
      available by phone throughout the course if not physically present. They are responsible for
      every aspect of the ITLS course and ensure that the program is consistent with ITLS
      standards and in the absence of an instructor, must be prepared to present information.

      A doctor interested in becoming a Course Medical Director must submit a completed Course
      Medical Director application along with curriculum vitae and letter stating intent to the Steering
      Committee. The applicant will be either denied, granted approval or Provisional Status.
      Provisional Status may be granted by the Chapter Medical Director pending the next Steering
      Committee Meeting.

      If written allegations are made regarding inappropriate conduct by or an inadequate
      knowledge base of the Course Medical Director, the Chapter Steering Committee may initiate
      an investigation. The Course Medical Director’s designation may also be suspended pending
      the outcome of the investigation. The Chairperson of the Chapter Steering Committee shall
      appoint a three member special committee to conduct the investigation. The Investigation
      shall be completed within sixty (60) days. Upon completion, the Course Medical Director will
      be informed, in writing, of the basis of the allegations and given an opportunity to refute the
      allegations, in writing, with in thirty (30) days. The special committee with then make
      recommendations for action including, but not limited to one or more of the following:

             Temporary suspension of the Course Medical Director
             Permanent suspension of Course Medical Director designation
             Remedial training
             Supervision by the Chapter Medical Director and/or Chapter Coordinator

.13   Chapter Executive Secretary- is the administrative designate of the ITLS Chapter. Should
      be an individual with organizational skills and abilities to manage databases, take meeting
      minutes and must act as a central point of information for all ITLS concerns. Responsibilities
      include facilitates the daily operation of the ITLS program in association with Chapter Medical
      Director and the Chapter Coordinator; monitors course paperwork to ensure compliance with
      state and national policies; reports to the Steering Committee all matters related to ITLS
      training; provide financial management and oversight of the ITLS Chapter including
      organization of chapter finances; organization of chapter records; provide administrative
      support for the ITLS chapter; execute the plans and enforce the policies of the ITLS Policy
      and Procedure Manual; and compiles and sends all necessary paperwork and information to
      the National ITLS office.

      The Chapter Executive Secretary is appointed by the Chapter Medical Director to a four year
      term and reappointment is at the Chapter Medical Director’s discretion.


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      The Chapter Executive Secretary can be removed by the Chapter Medical Director and
      Steering Committee.

.14   Chapter Coordinator – Must possess and maintain Affiliate Faculty status or be the
      administrative designate of the Chapter. Should demonstrate extensive experience managing
      continuing education programs and an in-depth knowledge of prehospital care. He/she must
      act as a central point of information for all ITLS concerns. Responsibilities include provide
      consistent leadership of the program; in association with Chapter Medical Director facilitates
      the daily operation of the ITLS program; Stimulate the evolution and consistency of ITLS
      programs throughout the chapter area; Provide financial management and oversight of the
      ITLS chapter including organization of chapter finances; ensure the quality and consistency of
      ITLS focusing primarily on the administrative aspects; advise the Chapter Steering Committee
      regarding the appointment of affiliate faculty; represent ITLS as an International Meeting
      Deligate; provide administrative support for the ITLS chapter; Execute the plans and enforce
      the policies of the ITLS Policy and Procedure Manual; and Coordinate due process activities
      of the Chapter Steering Committee.

      The Chapter Coordinator is appointed by the Chapter Medical Directing considering
      recommendation by the KY ITLS Steering Committee for a term of 4 years.

      If written allegations are made regarding inappropriate conduct by or an inadequate
      knowledge base of the Chapter Coordinator, the Chapter Steering Committee may initiate an
      investigation. The Chapter Coordinator’s designation may also be suspended pending the
      outcome of the investigation. The Chairperson of the Chapter Steering Committee shall
      appoint a three member special committee to conduct the investigation. The Investigation
      shall be completed within sixty (60) days. Upon completion, the Chapter Coordinator will be
      informed, in writing, of the basis of the allegations and given an opportunity to refute the
      allegations, in writing, with in thirty (30) days. The special committee with then make
      recommendations for action including, but not limited to one or more of the following:

          Temporary suspension of the Chapter Coordinator designation for a specified period of
           time
          Permanent suspension of Chapter Coordinator designation
          Remedial training
          Supervision by the Chapter Medical Director and/or Chapter Steering Committee


.15   International Meeting Delegate – ITLS International sponsors an annual meeting and
      conference for trauma education and for conducting business and elections for the ITLS
      International Board of Directors. The number of votes a chapter is awarded for the business
      session of the International Conference is determined by the number of ITLS certifications
      issued during the past two calendar years. In order for these certificates to be valid, payment
      must be submitted prior to March 31 of the next year. It is the prerogative of the KY ITLS
      Steering Committee to appoint delegates to accurately represent the interests of the chapter.
      Delegates should be an instructor or Affiliate Faculty, should have a strong working knowledge
      of ITLS and related issues and have an orientation by the Chapter Medical Director, Chapter
      Coordinator and/or the Steering Committee to the position. Responsibilities include represent
      the ITLS chapter as an International Meeting Delegate; communicate the perspective of the
      chapter with regard to major issues; disseminate information to all members of the steering
      committee as required; participate in the assessment of the ITLS program; participate in the
      formative process of continuing course revision; and participate in the development of ITLS
      International, Inc.



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      The ITLS Steering Committee and/or the Chapter Medical Director are responsible for
      appointing the International Meeting Delegates and their term covers the duration of the
      annual international meeting.

.16   Chapter Medical Director – Serves as the Chairperson of the ITLS Steering Committee.
      Must be a physician licensed to practice medicine within the Chapter. Must be a board
      certified Emergency Physician (A.B.E.M.) who is actively involved in emergency medicine with
      a demonstrated background of active involvement in pre-hospital care. He/she must be an
      ITLS instructor. Responsibilities include provide consistent leadership for the program;
      ultimately responsible for the management of the ITLS program within the chapter, in both
      educational and business- related matters; stimulate the evolution and consistency of ITLS
      programs throughout the chapter area; ensure the availability of training and the quality of the
      programs offered; ensure the medical appropriateness of the course content; ensure that the
      program is taught in a manner consistent with the EMS laws of the chapter; ensure the
      medical quality of ITLS courses throughout the chapter; advise the Chapter ITLS Steering
      Committee on the appointments of affiliate faculty; represent ITLS as an International Meeting
      Delegate, if possible; regularly review the courses held under the auspices of the appointed
      Course Directors within the chapter; relieve a Course Director of this title if he/she fails to
      present courses that are consistent with ITLS standards or where management of the courses
      impedes student education or the reputation of the Chapter ITLS Program; relieve a Affiliate
      Faculty of this title if he/she fails to present courses that are consistent with ITLS standards, or
      where management of the course impedes student education or the reputation of the Chapter
      ITLS Program; facilitates the daily operation of the ITLS Program in association with the
      Chapter Coordinator; and oversees the appeal of due process activities.

      The ITLS Chapter Medical Director is appointed by the KY Chapter of the American College of
      Emergency Physicians (ACEP) for a four year term.

      If written allegations are made regarding inappropriate conduct by or an inadequate
      knowledge base of the Chapter Medical Director, the Chapter Steering Committee may initiate
      an investigation. The Chapter Medical Director’s designation may also be suspended pending
      the outcome of the investigation. The Chairperson of the Chapter Steering Committee shall
      appoint a three member special committee to conduct the investigation. The Investigation
      shall be completed within sixty (60) days. Upon completion, the Chapter Medical Director will
      be informed, in writing, of the basis of the allegations and given an opportunity to refute the
      allegations, in writing, with in thirty (30) days. The special committee with then make
      recommendations for action including, but not limited to one or more of the following:

           Temporary suspension of the Chapter Medical Director designation for a specified
            period of time
           Permanent suspension of Chapter Medical Director designation
           Remedial training
           Supervision by the Chapter Steering Committee and/or Chapter Coordinator



Section 500 – Non-Discrimination and Harassment

01.   It is the policy of ITLS Kentucky that all our participants should be able to enjoy an educational
      environment free from all forms of discrimination, including sexual harassment.

      No person shall, on the basis of race, color, religion, sex, national origin, handicap, age or
      marital status be excluded from participation in, be denied the benefits of, or be subjected to
      discrimination under any ITLS Kentucky approved education program.


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      Such conduct, whether committed by instructors, affiliate, or participants, is specifically
      prohibited. This includes offensive sexual flirtations, advances or propositions; continued or
      repeated verbal abuse of a sexual nature; graphic or degrading verbal comments about an
      individual on his or her appearance; the display of sexually suggestive objects or pictures; or
      any offensive or abusive physical contact.

      In addition no one should imply or threaten that a participant’s “cooperation” of a sexual nature
      (or refusal thereof) will have any effect on the individual’s successful completion of the
      program, future instructional assignments or status as an affiliate faculty.

.02   ITLS Kentucky will not tolerate any instances of Human Rights violations. Any agency,
      organization, or group that conducts or sponsors and educational course approved by
      ITLS Kentucky is responsible for providing the above stated discrimination-free
      education environment, and should have available and on file a copy of this Policy.

.03   Any ITLS Kentucky approved educational program that does not comply with this policy shall
      be subject to sanctions, up to and including course decertification by ITLS Kentucky.

      Any participants of ITLS Kentucky approved educational program that does not comply with
      this policy shall be subject to sanctions up to and including decertification of Affiliate, Instructor
      and Provider certifications.

.04   Neither ITLS Kentucky nor ITLS International are liable for any actions arising from any EMS
      Agency, Training Center or other entity as a result of their hosting and/or conducting an ITLS
      Kentucky approved course.

.05   ITLS Kentucky shall comply with all of the appropriate rules and regulations current in the
      jurisdiction, territory, state, city, prefecture, parish or any other jurisdiction in which they will
      operate.


Section 600 – Dispute Resolution

.01   It is the policy of ITLS Kentucky that the following standard procedure should be followed to
      resolve any conflict that may arise between a student and an instructor regarding materials
      taught in a course; between a student and an instructor unrelated to material taught; and/or
      between two instructors.

.02   The student and instructor will first attempt to resolve the dispute by researching information
      in either the student textbook or the ITLS Kentucky Policy and Procedure Manual.

.03   If the dispute is not satisfactorily resolved with research as stated above, the student (and
      Instructor if needed) will go to either the Course Coordinator or the Affiliate Faculty member
      on-site.

.04   If the Course Coordinator or Affiliate Faculty member cannot satisfactorily resolve the
      dispute, the student (and instructor if needed) will consult the Chapter Coordinator.

.05   The Chapter Coordinator will contact staff at the ITLS International office as needed for
      additional assistance.

.06   ITLS Kentucky reserves the right to investigate all complaints brought to its attention and to
      proceed with disciplinary measures as deemed appropriate at the sole discretion of the


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       Chapter Coordinator and the Chapter Medical Director (or at the discretion of the executive
       director of ITLS International.


Section 700 – Regional Affiliate Faculty

.01    Regional Affiliate Faculty and At Large Instructors will be appointed by the following
       procedure: The Chapter Medical Director will appoint the Regional Affiliate Faculty and At
       Large Instructors from a list of appropriate affiliate faculty candidates from each region.

.02    Designated regions shall be defined as follows:

              Region 1        Eastern Kentucky – Clinton, Wayne, McCreary, Whitley, Knox, Bell,
                              Harlan, Russell, Pulaski, Laurel, Clay, Leslie, Perry, Letcher, Taylor,
                              Casey, Lincoln, Rockcastle, Jackson, Owsley, Breathitt, Knott, Floyd,
                              Pike, Boyle, Garrard, Madison, Estill, Lee, Wolfe, Magoffin, Mercer,
                              Jessamine, Fayette, Clark, Powell, Montgomery, Menifee, Morgan,
                              Johnson, Martin, Anderson, Woodford, Franklin, Scott, Bourbon,
                              Nicholas, Bath, Owen, Harrison, Robertson, Fleming, Rowan
              Region 2        Louisville - Green, Larue, Marion, Breckinridge, Hardin, Nelson,
                              Washington, Meade, Bullitt, Spencer, Jefferson, Shelby, Oldham,
                              Henry, Trimble, Carroll
              Region 3        Northern Kentucky - Gallatin, Grant, Pendleton, Bracken, Mason,
                              Boone, Kenton, Campbell

              Region 4        South Central/ Bowling Green – Logan, Simpson, Allen, Monroe,
                              Cumberland, Butler, Warren, Barren, Metcalfe, Adair, Ohio, Grayson,
                              Edmonson, Hart

              Region 5        Western Kentucky- Fulton, Hickman, Graves, Calloway, Carlisle,
                              Ballard, McCracken, Marshall, Livingston, Lyon, Crittenden, Caldwell,
                              Trigg, union, Webster, Hopkins, Christian, Henderson, McLean,
                              Muhlenberg, Todd, Daviess, Hancock

              Region 6        Steering Committee – Lewis, Carter, Elliot, Greenup, Boyd, Lawrence


.03    Regional Affiliate Faculty and At Large Instructors are expected to attend regular Chapter
       Committee meetings and deliver a report summarizing ITLS activities in their respective
       regions.

.04    Regional Affiliate Faculty and/or At Large Instructors are responsible for conducting instructor
       update classes and monitoring instructor performance within their region.

.05    Regional Affiliate Faculty should assist course coordinators with planning, staffing, equipment
       or other needs for conducting a course.

.06    Regional Affiliate Faculty should maintain a high interest level in ITLS during their term of duty.
       If they are unable to carry out the duties as specified, they must notify the Chapter Committee
       as soon as possible.

.07    Regional Affiliate Faculty must not have a conflict of interest with potential competing courses
       in his/her area. If a potential conflict exists, he/she must notify the ITLS office.



                                                 13
.08   Regional Affiliate Faculty shall make every attempt to attend as many courses in their region
      as possible to assure quality control at the individual courses.

.09   The ITLS Chapter Committee may vote to remove a Regional Affiliate Faculty from his/her
      position if it has been determined that individual is not active in ITLS activity based on
      attendance records and/or lack of participation in the region.

.10   A Regional Affiliate Faculty may be removed from his/her position at the discretion of the
      Chapter Medical Director.

Section 800 – Steering Committee and Steering Committee Meetings

.01   The Chapter shall periodically convene a Steering Committee comprised of: The Steering
      Committee of Kentucky International Trauma Life Support that consists of members
      appointed by the Kentucky International Trauma Life Support Medical Director. The
      members shall be, but are not limited to one (1) Kentucky International Trauma Life Support
      Chapter Coordinator, one (1) Kentucky International Trauma Life Support Executive
      Secretary, one (1) Kentucky International Trauma Life Support Affiliate Faculty, and one (1)
      Kentucky International Trauma Life Support Instructor. The terms of the appointees of the
      Steering Committee of Kentucky International Trauma Life Support shall be 3 years from
      date of appointment.

.02   The intent and purpose of an Steering Committee meeting is to address specific business and
      administrative issues related to the organization as determined by the Chairperson (Chapter
      Medical Director).

.03   A majority of the committee may be convened to gather facts, investigate complaints and
      enforce the policies and procedures of the organization.

.04   All parties that may be subject to an investigation of the facts in a Steering Committee Meeting
      shall be entitled to due process.

.05   The Steering Committee may remove a Regional Coordinator or Affiliate Faculty member after
      due process.

.06   Steering Committee members that may be involved in incidents that are under consideration
      as part of a Committee Meeting or Investigation shall be temporarily replaced by another
      member from the ITLS Chapter Committee.

.07   Any course participants, instructors, affiliate faculty or Chapter Committee members affected
      by actions taken, or recommendations made, as the result of a Committee Meeting or
      Investigation shall be notified in writing of such action or recommendation. Written notice must
      be given via certified, return-receipt mail.

.08   All decisions made in the Steering Committee Meeting shall be final unless overturned or
      changed following appeal by the person or persons affected. The Steering Committee has
      the right to restrict the teaching abilities of the complainant.

.09   Due Process shall be defined as the following: Within 60 days of receipt of complaint, the
      Steering Committee will investigate, determine validity and act on the complaint. The party will
      have 30 days to reply on the decision reached.




                                              14
                          RECORD OF CHAPTER OFFICIALS

The Chapter Policy & Procedure Manual should include a record of every chapter official, including
Medical Director(s), Coordinator(s), Chapter Committee Members, Chapter Executive Committee
Members, and Regional Coordinators as applicable. This record should be updated annually, or as
the positions change.

                                  January 2011 – January 2012


       Name                                  Position

1. Dr. Craig Carter                          Chapter Medical Director
2. Jeanne Hosp                               Chapter Coordinator
3. Beverly Jaco                              Chapter Executive Secretary
4. Mark Hodges                               Eastern Region Representative
5. Rockey Johnson                            Louisville Region Representative
6. Ed Harber                                 Northern Region Representative
7. Jim Williams                              South Central/ Bowling Green Region Representative
8. Daniel Carter                             Western Region Representative
9. Roger Godbehere                           At-Large Representative
10. Adam Peddicord                           At- Large Representative
11. Barbara Sauter                           At- Large Representative




Revised ____________

Updated ____________




                                            REV. 9/2011




                                               15
                         International Trauma Life Support
                                 Kentucky Chapter
                            Course Coordinator Checklist
     To be completed by Course Coordinators as they plan, organize and complete a course.


COURSE DATE: ______________________ COURSE NUMBER: ______________

LOCATION: __________________________________________________________


I.    THREE MONTHS BEFORE THE COURSE
      A.     Prepare budget ____

      B.     Request approval of course through CMS or from Chapter Committee ____

      C.     Identify and confirm
             1. Medical Director ____
             2. Course Coordinator ____
             3. Affiliate faculty ____

      D.     Arrange course facilities
             1. Course location ____
             2. Lodging ____
             3. Refreshments ____
                    a. Coffee ____
                    b. Lunches ____
                    c. Faculty dinner ____
             4. Course equipment
                    a. AV equipment ____
                    b. Projector ____
                    c. Podium ____
                    d. Skill station equipment ____
             (Refer to ITLS Instructor Manual)

      E.     Contact potential faculty, station assistants, patient models
             1. Faculty
                   a. ____
                   b. ____
                   c. ____
                   d. ____
             2. Station Assistants
                   a. ____
                   b. ____
             3. Patient Models
                   a. ____
                   b. ____

      F.     Arrange course schedule ____


                                           16
       G.   Create and distribute course advertisement ____

II.    TWO MONTHS BEFORE THE COURSE

       A.   Order textbooks ____


III.   ONE MONTH BEFORE THE COURSE

       A.   Prepare pre-course packets
            1. Student pre-course packets
                  a. Introductory letter ____
                  b. Hotel accommodation information ____
                  c. ITLS textbook ____
                  d. Pretest ____
                  e. Course agenda ____
                  f. Map ____
                  g. ITLS specialty items order form ____
            2. Faculty pre-course packets
                  a. Introductory letter with assignments ____
                  b. Hotel accommodation information ____
                  c. Lecture slides ____
                  d. Course schedule ____
                  e. Course material ____
                  f. Testing scenario ____
                  g. Map ____

       B.   Mail textbooks and pre-course packets to students ____

       C.   Mail pre-course packets to faculty ____


IV.    TWO WEEKS BEFORE THE COURSE

       A.   Confirm patient models ____

       B.   Confirm station assistants ____

       C.   On-site packets
            1. Course Students ____
                  a. Name tag ____
                  b. Final course schedule ____
                  c. Faculty list ____
                  d. Student list ____
                  e. Rotation schedule ____
                  f. Course evaluation forms ____
            2. Faculty
                  a. Name tag ____
                  b. Final course schedule ____
                  c. Faculty list ____


                                         17
                  d. Student list ____

V.     DAY BEFORE THE COURSE

       A.   Equipment placed in staging area ____

       B.   Pre-course faculty meeting ____

       C.   Arrange educational facility ____


VI.    DAY OF THE COURSE

       A.   Arrive early to confirm seating, temperature, refreshments and registration
            area ____

       B.   Register students ____

       C.   Introduce faculty ____

       D.   Set-up skill stations ____

       E.   Moulage models ____

       F.   Faculty meetings as necessary ____

       G.   Provide feedback to students ____

       H.   Conduct post-course faculty meeting ____


VII.   POST COURSE

       A.   Thank-you letters to faculty, station assistants and patient models ____

       B.   Course report forms and fees forwarded to the chapter office ____

       C.   Reimburse faculty and staff ____

       D.   Distribute course completion cards ____




                                         18
                      International Trauma Life Support
                              Kentucky Chapter
                Proposed Course Budget & Financial Summary
     To be completed by Course Coordinators as they plan, organize and complete a course.


COURSE DATE: ______________________ COURSE NUMBER: ______________

LOCATION: __________________________________________________________


RECEIPTS:
I. Tuition:
_______ Participants @ $ _____ each
TOTAL $_____

II. OTHER GRANT MONIES (IF APPLICABLE): $ _______
TOTAL RECEIPTS $ _______
DISBURSEMENTS:

I. Travel Expenses / Subsistence
A. Faculty & Staff
1. ______________________________ $ _______
2. ______________________________ $ _______
3. ______________________________ $ _______
4. ______________________________ $_______
5. ______________________________ $ _______
6. ______________________________ $ _______
7. ______________________________ $ _______
8. ______________________________ $ _______

B. Coordinator
1. ______________________________ $ _______

C. Assistants (Station assistants and Patient models, etc.)
1. ______________________________ $ _______
2. ______________________________ $ _______
3. ______________________________ $ _______
4. ______________________________ $ _______
5. ______________________________ $ _______
6. ______________________________ $ _______
7. ______________________________ $ _______
8. ______________________________ $ _______

II. Course Equipment/Material
A. Material
1. ____________ $ _______
2. ____________ $ _______

B. Office Supplies/ Services


                                           19
1. Postage $ _______
2. Photocopies $ _______
3. _______________________________ $ _______
4. _______________________________ $ _______
5. _______________________________ $_______


C. Expendable Equipment
1. ________________________________ $ _______
2. ________________________________ $ _______
3. ________________________________ $ _______
4. ________________________________ $ _______

D. Non expendable Equipment
1. ________________________________ $ _______
2. ________________________________ $ _______
3. ________________________________ $ _______
4. ________________________________ $ _______

E. Facilities/Services
1. Room Rental $ _______
2. Audio-Visual Rental $ _______
3. Coffee Break(s) $_______
4. Lunch (es) $ _______
5. Dinner(s) $ _______
6. Administrative Charges $ _______
7. ___________________ $ _______
TOTAL $ _______

III. Indirect Cost Charges
A. ITLS Chapter fee
_______ Participants @ $ _____ each
B. ITLS International fee
________Participants @ $ _____ each

TOTAL $_______

TOTAL RECEIPTS $ _______

Minus TOTAL DISBURSEMENTS $ _______

TOTAL NET GAIN OR LOSS $ _______


COURSE COORDINATOR                    DATE
______________________                       _____________




                                       20
                             International Trauma Life Support
                                     Kentucky Chapter
                                   Post-Course Checklist
  This checklist must be sent to the Chapter Office along with any borrowed course materials no
                                more than 10 days after the course.

COURSE COORDINATOR: _____________________________________________________

COURSE DATE: _________________________ COURSE NUMBER: ___________________

LOCATION: __________________________________________________________________

1. Responsible party for payment of fees: _________________________________________________

Need Invoice: Yes       No

Send Invoice to: _____________________________________________________________________
Attention of: ________________________________________________________________________
Street Address: _________________________________________ City: ________________________
State/Province: ________________ Country: __________________ Zip/Postal Code: _____________
Home Phone No.: ___________________________ Work Phone No.: __________________________
2. Cards & Certificates:
Mail Cards & Certificates to: ___________________________________________________________
Attention of: ________________________________________________________________________
Street Address: _________________________________________ City: ________________________
State/Province: ________________ Country: __________________ Zip/Postal Code: _____________
Home Phone No.: ___________________________ Work Phone No.: __________________________

The following items have been sent to the Chapter Office:
(Please put an "X" after each item enclosed)

1. Complete ITLS course roster ______
(Typed list of participants’ names and addresses)

2. Typed faculty roster ______

3. Post tests ______

4. Score sheets ______

5. Evaluations ______

6. Payment of fees ______ (Request invoice if needed)


For office use only
Paperwork received: ________________ International Fees Paid: __________________
Fees Invoiced: _____________________ Fees Received: ________________________




                                                21
                          International Trauma Life Support
                                  Kentucky Chapter
                              Course Roster Tally Sheet
  To be completed by Course Coordinators after a course to determine the amount of money for
         student fees owed to the Chapter. Use of CMS eliminates the need for this form.


Chapter Name: ___________________________________________________________

Type of Course: ___________________________________________________________

Date of Course: ___________________________________________________________

Course Location: __________________________________________________________

Course Coordinator: ________________________________________________________



Total number of students: $ ____________

Course Fees (See Table): $____________

Multiply Number of Students by Course Fee For:

Total Amount Due: $ ____________


Please remit this completed Course Tally Sheet with completed Course Rosters and fees to:

Kentucky ITLS
P.O. Box 562
Lawrenceburg, KY 40342




Course Fees per student

Basic Provider: $25.00
Advanced Provider: $25.00
Basic Instructor: $25.00
Advanced Instructor: $25.00




                                                 22
              SAMPLE CONFIRMATION LETTER TO INSTRUCTORS


Date:

To: ITLS Instructors

From: Course Director

RE: Assignments - Course Location and Date

Thank you for your agreement to serve as an instructor at the <TYPE OF COURSE> to be
held on <DATE OF COURSE> at <NAME OF FACILITY>, <MAILING ADDRESS>.

Agendas indicating the assignment of lectures, skill stations and patient assessment testing are
enclosed. Your assignments are highlighted on the agendas.

If you are lecturing, the slides for your topic are enclosed. They should be returned to
<COURSE COORDINATOR> immediately following your lecture.

Please review the ITLS Instructor Guide for station objectives and important points when preparing
for the teaching stations. For patient evaluation and testing, we have enclosed a copy of your
assigned scenario. Instructors are responsible for orienting the models to their roles prior to the
testing session.

Enclosed are:
• A map indicating the general area of the course location
• Faculty informational material
• Scenarios for the testing stations
• Course agendas
• Slides for lecturing

If you have any questions, please contact <COURSE COORDINATOR> at <PHONE NUMBER> or
<EMAIL ADDRESS>.

Sincerely,

Course Director


+Enclosures




                                                23
        SAMPLE CONFIRMATION LETTER TO COURSE REGISTRANTS


Date:

Dear ITLS Registrant:

Thank you for registering for the ITLS <TYPE OF COURSE> to be held on <DATE OF COURSE>
at <NAME OF FACILITY>, <MAILING ADDRESS>.

Enclosed you will find the following materials:
• ITLS textbook
• Pretest and answer sheet
• Course agenda
• Map with directions to course location

The <TYPE OF COURSE> is an intense, <COURSE LENGTH> learning experience that consists
of didactic presentations, skill stations, a written examination and patient assessment testing. It is
extremely important that you be familiar with the text and be well prepared prior to the course. Take
the pretest after you have studied the text. Check your responses with the answer key provided.

We suggest you wear casual clothes. Several skill stations require floor work with various types of
equipment.

If you have any questions, please contact <COURSE COORDINATOR> at <PHONE NUMBER> or
<EMAIL ADDRESS>. We look forward to seeing you at the course!


Sincerely,


Course Director

+Enclosures




                                               24
                           International Trauma Life Support
                                     Kentucky Chapter
                           Affiliate Faculty Course Evaluation
             To be completed by affiliate faculty member(s) at the completion of course.


Course Coordinator:

CMS Course Number:

Assistant Course Coordinator:

Medical Director:


Course Information:

Type: Advanced / Basic / Combined / Completer
      Recertification / Initial / Instructor

Location:

No. of students:
No. of faculty:
No. of teaching stations:
No. of faculty at each teaching station:
No. of testing stations:

Please indicate the number of students for each category:

Basic Course:         Passed: ______ Incomplete: _______ Retest: _______

Advanced Course: Passed: ______ Incomplete: _______ Retest: _______

Comments:




Name (printed):

Signature:

Date:


                                               25
                          International Trauma Life Support
                                  Kentucky Chapter
                             Provider Course Application
        To be completed by individuals or organizations requesting the Chapter’s assistance
           in organizing and coordinating an initial ITLS Provider Course at their location


Name: __________________________________________________________________

Home address: ___________________________________________________________

Work address: ____________________________________________________________

Home phone: ( )______________________ Work phone: ( )________________________

Degree(s): _______________________________________________________________

Affiliation: _______________________________________________________________

Requested Course Date: ____________________________________________________

Proposed Course Location: __________________________________________________

Sponsoring agency (if any): __________________________________________________

Have you ever attended an ITLS course before?       Yes No
If Yes, when and where? ____________________________________________________

Have you ever attended any trauma-training program? Yes No
If Yes, what course, when and where? _________________________________________

How did you learn about ITLS? _____________________________________________



Tuition Fee Enclosed: $ _________

Method of payment: Money Order / Check / Cash




Name (printed):

Signature:

Date:


                                              26
                          International Trauma Life Support
                                  Kentucky Chapter
                            Instructor Course Application
        To be completed by individuals or organizations requesting the Chapter’s assistance
          in organizing and coordinating an initial ITLS Instructor Course at their location


Name: __________________________________________________________________

Home address: ___________________________________________________________

Work address: ____________________________________________________________

Home phone: ( )______________________ Work phone: ( )________________________

Degree(s): _______________________________________________________________

Affiliation: _______________________________________________________________

Requested Course date: ____________________________________________________

Proposed Course Location: __________________________________________________

Sponsoring agency (if any): __________________________________________________

Provider Course Date: ______________________________________________________

Location of Provider Course: _________________________________________________

Name of Intended Course Medical Director (if any): _______________________________



Tuition Fee Enclosed: $ _________

Method of payment: Money Order / Check / Cash



Name (printed):

Signature:

Date:




                                              27
                            International Trauma Life Support
                                    Kentucky Chapter
                               Instructor Reciprocity Form
    To be completed by individuals requesting reciprocity as ITLS Instructors within a Chapter
                different from the Chapter in which certification was completed.



Name: _________________________________________________________________

Address: _______________________________________________________________

Home phone: ( )______________________ Work phone: ( )_______________________

Medical Credentials: EMT-B EMT-I             EMT-P RN         PA    Physician Other: ___________

Location of instructor course: _______________________________________________

Name of Medical director: __________________________________________________

Date instructor course conducted: ____________________________________________

The Chapter Coordinator may request a copy of your current ITLS Instructor card.


        A PHTLS or ATLS instructor may become an ITLS instructor following successful completion
        of an ITLS provider course. The Instructor must then apply to the Chapter Coordinator
        requesting reciprocity. The Instructor must also provide any past activities regarding PHTLS
        instruction and a letter confirming good standing from their former Chapter Coordinator.
        After completion, the Chapter’s policies for provisional instructors will apply and must include
        monitoring.




Name (printed):

Signature:

Date:




                                                 28
                            International Trauma Life Support
                                    Kentucky Chapter
                          Instructor Recertification Application
        To be completed by instructors requesting recertification status and new instructor card


Name: _________________________________________________________________

Address: _______________________________________________________________

Home phone: ( )______________________ Work phone: ( )_______________________

Fax phone:

Email:

Medical Credentials: EMT-B EMT-I            EMT-P RN          PA   Physician Other: ___________

NREMT Number:                                          Expiration Date:

State Number:                                          Expiration Date:

Languages Spoken: English            Spanish      Other:

Date of Expiration: ______________            Type: Basic            Advanced      Pediatric

As a ITLS instructor, you are required to instruct one course per year. Please complete the
form below with the appropriate information and submit it to the Chapter office.


Date            Course Type           Location                       Course Coordinator




Lecture Assignment                    Skills Station                 Patient Assessment




Name of Instructor:

Signature:

Date:


                                                 29
                     International Trauma Life Support
                             Kentucky Chapter
                             Registration Form
                     To be completed by each student in the class.



Name:

Address:

City:                                         State:                 Zip:

Home Phone:                                   Work Phone:

Fax Number:

Email:

Medical Credentials: EMT-B EMT-I    EMT-P RN           PA   Physician Other: ___________

NREMT Number:                                Expiration Date:

State Number:                                Expiration Date:

Languages Spoken: English    Spanish      Other:




                                        30
                           International Trauma Life Support
                                   Kentucky Chapter
                              Provider Course Evaluation

                   To be completed by participants at the conclusion of the course.

Course Coordinator:
Course Date:
Course Location:


Please rate all of the following course components on a scale of 1-5, with 5 being the best.
When rating each component, consider the following:

       The instructor was organized
       The instructor seemed interested in the students
       Understanding of the material presented
       The instructor was effective, clear, informative and knowledgeable on the topic



LECTURES                                            Excellent…………….……..Poor

Mechanism of Motion Injury                                  5      4      3       2       1
Patient Assessment & Load and Go                            5      4      3       2       1
Patient Assessment Demonstration                            5      4      3       2       1
Airway Management of the Trauma Victim                      5      4      3       2       1
Chest Trauma                                                5      4      3       2       1
Abdominal Trauma                                            5      4      3       2       1
Shock Evaluation and Management                             5      4      3       2       1
Blood and Body Fluid Precautions                            5      4      3       2       1
Burns                                                       5      4      3       2       1
Head Trauma                                                 5      4      3       2       1
Spinal Trauma                                               5      4      3       2       1
Trauma in Pregnancy                                         5      4      3       2       1
Trauma in Children                                          5      4      3       2       1
Trauma in the Elderly                                       5      4      3       2       1
Extremity Trauma                                            5      4      3       2       1
Patients under the Influence of Drugs                       5      4      3       2       1
Trauma Cardiorespiratory Arrest                             5      4      3       2       1


                                               31
SKILLS STATIONS

Basic Airway Management                               5      4     3    2      1
Spine Management Skills                               5      4     3    2      1
Traction Splints                                      5      4     3    2      1
Helmet Management                                     5      4     3    2      1
Spine Management Skills II                            5      4     3    2      1
Primary Survey                                        5      4     3    2      1
Secondary Survey                                      5      4     3    2      1
Putting It All Together                               5      4     3    2      1
Advanced Airway Management                            5      4     3    2      1
Chest Decompression / Fluid Resuscitation             5      4     3    2      1


OVERALL COURSE                                        5      4     3    2      1




We appreciate any comments to help make the course a better experience for future
students:




                           Thank you for your time and comments.


                                          32
                               International Trauma Life Support
                                       Kentucky Chapter
                                    Instructor Monitor Form

                To be completed by Affiliate Faculty on all Instructor Candidates.

Candidates Name:

Address:

Certification Level: EMT-B        EMT-I      EMT-P      RN   PA-C   MD   Other:

Years at current level:

Course Location:                                               Course Date:

CMS Course Number:

THE FOLLOWING SHOULD BE COMPLETED BY THE MONITORING AFFILIATE FACULTY

   1. Didactic Presentation                      Excellent………………..….Unacceptable
              Topic:
                     Overall knowledge                         4     3        2   1
                          Speaking ability                     4     3        2   1
                          Ability to handle questions          4     3        2   1
                          Use of audiovisuals                  4     3        2   1
   2. Skill Station
               Topic:
                          Knowledge of objectives              4     3        2   1
                          Presentation                         4     3        2   1
                          Teaching aids used frequently        4     3        2   1
                          Ability to handle questions          4     3        2   1
   3. Patient Assessment Stations
              Topic:
                     Knowledge of objectives                   4     3        2   1
                          Presentation of scenarios            4     3        2   1
                          Documentation                        4     3        2   1
Average of scores:                               (Score must average 3 or better for completeion)

Comments:



Affiliate Faculty Who Monitored Candidate:                                        Date:

     Check One:
           Candidate has met expectations.
           Candidate needs further teaching experience and re-evaluation.
                                                     33
                           International Trauma Life Support
                                    Kentucky Chapter
                        Affiliate Faculty Application Information

Affiliate Faculty positions are appointed by the Medical Director for the State Chapter after review
of the recommendation of the Steering Committee. The duties of an Affiliate Faculty are to monitor
the quality of BTLS courses within the Chapter, to monitor new instructors, and to teach and
provide instructor courses and instructor update training. In addition, Affiliate Faculty members shall
serve as an information resource for instructors in their geographic area and assist instructors in
developing and planning BTLS provider courses.

                  In order to be appointed as an Affiliate Faculty,
                an individual must met the following requirements:
   Submit a letter of request to the Chapter Steering Committee and complete the required
    application form, and
   Be a currently certified Advanced Level Instructor in good standing with the Kentucky Chapter
    or other Chapter where an applicant may have been previously affiliated, and
   Must have been an Advanced Level Instructor for at least two consecutive years preceding the
    date of application, and
   Hold current state licensure/certification and be in good standing with the licensing/certifying
    agency at a level commensurate with that required to be an Advanced Level Instructor, and
   Have served as an Advanced Level Instructor in at least four provider courses, and
   Have served as the Course Coordinator in at least two additional courses, and
   Submit 2 letters of recommendation from a currently certified Affiliate Faculty, who is in good
    standing with the Kentucky Chapter, and
   Document the need for the Affiliate position in the geographical area in which the applicant
    resides through letters of support. (i.e. letters from Training Officers in agencies that would
    potentially utilize the Affiliate Faculty or from other Affiliate Faculty in contiguous geographical
    areas)

Applications must be submitted at least 60 calendar days prior to a Steering Committee meeting in
order for the application to be considered at that meeting. Applications not submitted in the
designated time frame will be held until the next Steering Committee meeting in order to allow staff
sufficient time to research and verify the applicant’s information.

Once all of the required information is submitted, the Executive Secretary will review the
information and verify that the applicant is in good standing with the Chapter and other Chapters
where the applicant may have previously served. In addition, the Executive Secretary will verify the
present standing of licenses/certifications held with the appropriate agencies. The application will
be forwarded to the State Steering Committee who will review the information. The applicant will be
expected to attend the Steering Committee meeting at which their application will be reviewed. An
application will not be reviewed without the applicant being present. Steering Committee members
will be allowed to question the applicant during the Steering Committee meeting. Once the
documents have been reviewed and any questioning of the candidate completed by the Steering
Committee, a vote will be taken regarding a favorable or unfavorable recommendation of the
candidate for provisional appointment.

Once the Chapter Medical Director and Steering Committee has recommended the candidate for
provisional appointment, they must then be monitored by an Affiliate Faculty member of the State


                                                 34
Steering Committee while acting in the role of an Affiliate Faculty for a provider course. During this
time they will be expected to fulfill all of the roles and responsibilities of an Affiliate. The Steering
Committee

Affiliate Faculty member will complete a written evaluation of the candidates’ performance and
forward that document to the Steering Committee for review. After review of the evaluation
document, the Steering Committee will make a final recommendation to the Chapter Medical
Director regarding the formal appointment of the candidate.

The State Office or the Steering Committee will notify the candidate of their final ruling and issue
any certification documents as may be appropriate. Any applicant denied appointment and later
reapplies for appointment must upon reapplication complete the entire prescribed application/
monitoring process.

                               Affiliate Faculty Appointment Period
The initial appointment period will be for varying periods but not to exceed three years. All
subsequent reappointments shall be for a period of three years.

                                       Affiliate Faculty Renewal
An Affiliate must teach or serve in the Affiliate role in a minimum of two provider courses in a two
year period in order to maintain their Affiliate status. In addition, the Affiliate must be in good
standing with the State Chapter, recommended for renewal by the Chapter staff and Medical
Director and all course fees must be current with the State Chapter.




                                                 35
                            International Trauma Life Support
                                     Kentucky Chapter
                               Affiliate Faculty Application

_______________________ _______________________ _____________________
Last Name                           First Name                          Middle/Maiden Name

_______________________________________________________________________________
Street Address                    City        County       State        Zip Code

_______________________________________________________________________________
Mailing Address If Different From Above City  County        State       Zip Code

_______________________________________________________________________________
 Name of Employer                                           Position Held

_______________________________________________________________________________
Address of Employer               City       County         State      Zip Code

(___)_____-______ (___)______-______                ____-_____-_____                _____-_____-_____
 Home Phone           Business Phone               Social Security Number              Date Of Birth
   Licenses / Certifications Held                          STAFF USE ONLY
   Please attach a copy of each
                                       Instructor in Courses Verified:           ____ YES ____ NO
  _______ EMT – Basic                  Course Coordinator Courses Verified:      ____ YES ____ NO
  _______ EMT – Paramedic              License/Certification in Good Standing:   ____ YES ____ NO
  _______ NO                           License/Certification Current:            ____ YES ____ NO
  _______ LPN                          Letter of request Received:               ____ YES ____ NO
  _______ RN                           Application Complete:                     ____ YES ____ NO
  _______ ACLS                         All Course Fees Current :                 ____ YES ____ NO
  _______ PALS                         Affiliate Recommendation Letter(s):       ____ YES ____ NO
  _______ BTLS                         Justification of Need Letter(s):          ____ YES ____ NO
  _______ PHTLS                        Two Year Length of Service Verified:      ____ YES ____ NO
  _______ TNCC                         Scheduled for Meeting On:                 ________________
  _______ CEN                          Candidate Notified On:                    ________________
  _______ Other – Please List                                                    BY: _____________
  ___________________________          Recommended for Provisional:              ____ YES ____ NO
  ___________________________          Monitor Date:                             ________________
  ___________________________                                                    AT: _____________
                                       Affiliate Monitor:                        ________________
                                       Recommended for Final Appointment:        ____ YES ____ NO
                                       Medical Director Signature:
                                                 ________________
I verify that all of the information contained in this application is accurate and true. I have read and
understand the information contained in the accompanying Affiliate Faculty Application Information.
I understand that my appointment is subject to remaining in good standing with the Chapter and
meeting the renewal requirements listed. I understand that any information provided to the Chapter
or the Steering Committee on this or subsequent documents, which is found to be false will be
grounds for revocation of any appointment made by the Chapter.



Applicant Signature: __________________________________ Date:



                                                 36
                         International Trauma Life Support
                                 Kentucky Chapter
                      Course Medical Director Application Form


Name:                                               Social Security Number: XXX-XX-
                                                                            Last 4 Digits Only
Home Address:



Work Address:



Home Phone:                                         Work Phone:

Fax Phone:

Email:

Affiliation:

Primary Specialty:                                  Board Certified:       Yes     No

Have you taken ITLS?          Yes        No         Date of course:

Have you taken ATLS?          Yes        No         Date of course:

Have you taken an ITLS Instructor Course?           Yes       No
(if not would you be willing to take ITLS Instructors Course?      Yes      No)


ITLS Course information, which you are requesting to be medical director of:

Course Location:

Sponsoring Agency:

Provider course date:

Course Coordinator:

Affiliate Faculty:

Please note: Course Medical directors are responsible to ensure that the course is consistent with
ITLS standards and are ultimately responsible for every aspect of the ITLS course. Do you agree
to follow the standards outlined in the KY ITLS Policy Manual?



Signature:                                                         Date:



                                               37
                                    International Trauma Life Support
                                            Kentucky Chapter
                                           Patient Assessment
STUDENT NAME_____________________________________ SCENARIO #                                BASIC          ADVANCED

DATE_____________________                PRACTICE_______                  TEST_______               RETEST_______

TIME STARTED_________ TIME COMPLETED_________ TIME TRANSPORTED_________ COMPLETED DETAIL_________

SCENE SURVEY                                                  DETAILED EXAM
_____BODY SUBSTANCE ISOLATION                                 _____SAMPLE HISTORY
_____SCENE HAZARDS                                            _____B/P_____PULSE_____RESP_____MONITOR EKG
_____NUMBER OF PATIENTS                                       _____O2 SATS_____BLOOD GLUCOSE FOR ALTERED LOC
_____ADDITIONAL HELP OR EQUIPMENT                             _____NEURO EXAM (AVPU) _____GCS_____PUPILS PEARL
_____MECHANISM OF INJURY                                      _____ETREMITIES PMS_____CUSHINGS RESPONSE
                                                              _____MEDICAL IDENTIFICATION DEVICES
INTIAL ASSESSMENT                                             _____HEAD_____DCAP_____TIC_____BLS
_____GENERAL IMPRESSION OF PATIENT                            _____BATTLE’S SIGN_____RACCOON EYES
_____C-SPINE CONTROL                                          _____CHECK EARS & NOSE –BLOOD & FLUID
_____LEVEL OF CONCIOUSNESS - AVPU                             _____ PUPILS = OR NOT =, REACTIVE
_____IS AIRWAY OPEN _____ CLEAR                               _____SKIN COLOR_____TEMP_____MOISTURE_____CAP REFILL
_____AIRWAY INTERVENTIONS                                     _____AIRWAY, OPEN & CLEAR_____SIGNS OF BURNS
_____ BREATHING_____RATE _____ QUALITY                        _____BREATHING_____RATE_____QUALITY
_____VENTILATION INSTRUCTIONS                                 _____CIRCULATION_____RATE_____QUALITY
_____LPM_____NC_____NRB_____BVM_____POCKET MASK               _____SKIN COLOR_____TEMP_____MOISTURE
_____RADIAL PULSE_____CAROTID PULSE                                 _____ CAP REFILL (IF NOT DONE ABOVE)
_____SKIN COLOR_____TEMP_____MOISTURE_____CAP REFILL          _____NECK_____DCAP_____TIC_____BLS
_____NOTES LIFE THREATENING BLEED_____CONTROLS                _____NECK VEINS_____NORMAL_____FLAT_____DISTENDED
                                                              _____TRACHEA_____MIDLINE_____DEVIATED
RAPID TRAUMA SURVEY
                                                              _____CHEST_____DCAP(P) _____TIC_____BLS
_____CHECK HEAD _____ DCAP_____TIC_____ BLS
                                                              _____LUNG SOUNDS_____CLEAR_____EQUAL_____UNEQUAL
_____CHECK NECK _____ DCAP_____TIC_____ BLS
                                                              _____PERCUSSES (PRN)
_____CHECK FOR JVD_____TRACHEA DEVIATION
                                                              _____HEART SOUNDS_____CLEAR_____MUFFLED
_____C-COLLAR APPLIED
                                                              _____IF INTUBATED, ET TUBE POSITION
_____CHECK CHEST_____DCAP(P) _____TIC_____ BLS
                                                              _____ABDOMEN_____DCAP_____TIC_____BLS
     _____PERCUSSES (PRN)
                                                              _____PELVIS (IF NOT CHECKED IN PRIMARY)
_____CHECK BREATH SOUNDS _____CLEAR_____= OR NOT =
                                                                    _____DCAP_____ TIC_____BLS
_____CHECK HEART SOUNDS_____CLEAR_____MUFFLED
                                                              _____LEGS_____DCAP_____TIC_____BLS_____PMS_____ROM
_____CHECK ABDOMEN_____DCAP_____TIC_____BLS
                                                              _____ARMS_____DCAP_____TIC_____BLS_____PMS_____ROM
_____CHECK PELVIS_____DCAP_____TIC_____BLS
_____CHECK LOWER EXTREMITIES_____DCAP_____TIC
     _____BLS_____PMS
                                                              ONGOING ASSESSMENT
_____CHECK UPPER EXTREMITIES_____DCAP_____TIC                 _____ASK PATIENT ABOUT CHANGES IN HOW HE FEELS
     _____BLS_____PMS                                         _____REASSESS MENTAL STATUS (LOC, PUPILS, GCS)
_____ALTERED MENTAL STATUS => DO BRIEF NEURO BELOW            _____CHECK AIRWAY
_____CHECK BACK _____DCAP_____TIC_____BLS                     _____CHECK BREATHING RATE & QUALITY
_____CRITICAL SITUATION DECISION                              _____CHECK CIRCULATION (BP & HR)
_____TRANSPORT                                                _____SKIN COLOR, CONDITION, TEMPERATURE
                                                              _____CHECK NECK (TRACHEA & VEINS)
          IF ALTERED MENTAL STATUS                            _____CHECK CHEST (BREATH SOUNDS)
               => DO BRIEF NEURO                              _____PERCUSSION (PRN)
_____PUPILS = OR NOT =, REACTIVE
_____GLASGOW COMA SCALE                                       _____CHECK ABDOMEN FOR TENDERNESS
_____SIGNS OF CUSHING RESPONSE                                _____FOCUSED ASSESSMENT FOR INJURIES
_____MEDICAL IDENTIFICATION DEVICES                           _____RECHECK ALL INTERVENTIONS
_____SAMPLE HISTORY
_____VITAL SIGNS_____BP_____HR_____RESP

GRADE KEY
 √ COMPLETED, SKILL PERFORMED IN SEQUENCE D DELAYED, PERFORMED OUT OF SEQUENCE X SKILL NOT PERFORMED, TOO LATE OR INCORRECTLY


                                                           38
                                      CRITICAL ACTIONS
_____COMPLETES SCENE SIZE-UP AND USES UNIVERSAL PRECAUTIONS
_____PERFORMS INITIAL ASSESSMENT AND INTERACTS WITH PATIENT
_____PERFORMS ORGANIZED RAPID TRAUMA SURVEY OR FOCUSED EXAM
_____ENSURES SPINAL MOTION RESTRICTION
_____ENSURES APPROPRIATE OXYGENATION AND VENTILATION
_____RECOGNIZES AND TREATS ALL LIFE-THREATENING INJURIES
_____USES APPROPRIATE EQUIPMENT AND TECHNIGUES
_____RECOGNIZES CRITICAL TRAUMA, TIME AND TRANSPORT PRIORTIES
_____PERFORMS DETAILED EXAM (WHEN TIME PERMITS)


                                     IMPORTANT ACTIONS

_____PERFORMS ONGOING EXAM (WHEN TIME PERMITS)
_____UTILIZES TIME EFFICIENTY
_____GIVES APPROPRIATE REPORT TO MEDICAL ADVISOR
_____DEMOSTRATES ACCEPTABLE SKILL TECHNIQUES
_____DISPLAYS LEADERSHIP AND TEAMWORK


                                   INSTRUCTOR COMMENTS




                                       OVERALL GRADE

_____ EXCELLENT _____ GOOD _____ ADEQUATE           _____ INADEQUATE

FURTHER COMMENTS




LEAD INSTRUCTOR NAME / SIGNATURE____________________________________________________

INSTRUCTOR NAME / SIGNATURE__________________________________________________________

INSTRUCTOR NAME / SIGNATURE__________________________________________________________




                                               39

								
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