Name:

APPLICATION FOR
CLINICAL PRIVILEGES
Date :
PEDIATRIC

INSTRUCTIONS TO APPLICANT:
Please check [√] the privileges and procedures which you are requesting. By checking these privileges and procedures you are
also stating that you believe yourself to be competent and experienced in each. Sign and date at the end of the form.

GENERAL PRIVILEGES SPECIAL PRIVILEGES

General Pediatric Privileges Exchange transfusion
Neonatology privileges Ventilator management
Consultation in Subspecialty Elective endotracheal intubation
1. Elective cardioversion
Insertion of peripheral alimentation line
Pericardiocentesis
GENERAL PROCEDURES
Subdural tap
ALL OF THE BELOW Ventricular shunt tap
Lumbar puncture Cancer chemotherapy ( peds oncology only)
Suprapubic bladder aspiration Peripherals venous cutdown
Bone Marrow aspiration/ biopsy
Bladder catheterisation
Paracentesis OTHERS
Thoracocentesis
Thoracostomy tube replacement
Insertion of arterial line (umbilical)
Insertion of arterial line (peripheral)
Insertion of central venous line
Intra- osseous access

**Privileges to perform emergency lifesaving procedures are automatically granted to all staff physicians.

Signature of Applicant Date:

Signature of Facility CMS Date:

Name of facility

Signature of Group Medical Director Date:

Verification and comments (if any):

NU/TRIAL/JULY12
MED020/AUG12
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