Privilege request form
Trauma surgery
In order to be eligible to request clinical privileges in trauma surgery, an applicant must meet the
following minimum threshold criteria:
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Education: MD or DO.
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Minimum formal training: Applicants must complete an ACGME/AOA-accredited residency
program in general surgery, followed by completion of a fellowship program in trauma surgery
or critical care surgery.

Required previous experience: Applicants must demonstrate that they managed at least 50
trauma surgery cases in the past 12 months.

References: A letter of reference should come from the director of the applicant’s trauma
surgery or critical care surgery fellowship program. Alternatively, a letter of reference
regarding competence should come from the chief of trauma surgery at the institution where the
applicant most recently practiced.
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Core privileges in trauma surgery: Core privileges in trauma surgery include the following:
 Resuscitate and accurately diagnose injuries in the trauma victim
 Intervene surgically after diagnostic studies are performed and coordinate operative
procedures to be performed by subspecialty consultants
 Supervise/perform all necessary operative cases
 Manage the trauma patient throughout the stay in the acute-care facility as well as
coordinate the early institution of rehabilitation and discharge planning

Additional considerations: Applicants should achieve ATLS provider status.

Reappointment: Reappointment should be based on unbiased, objective results of care
according to the organization’s existing quality assurance mechanisms.
Applicants must demonstrate their maintained competence with evidence that they managed at least
100 trauma surgery cases in the past 24 months.
In addition, continuing education related to trauma surgery and critical care surgery should be
required.
I understand that by making this request I am bound by the applicable bylaws or policies of the
hospital, and hereby stipulate that I meet the minimum threshold criteria for this request.
Physician’s signature:___________________________________
Typed or printed name:__________________________________
Date: _______________________________________________