INTERNATIONAL TRAUMA LIFE SUPPORT
POLICY AND PROCEDURE
Table of Contents
I.
II.
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
SAMPLE FORMS
pages 16-38
1
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
2
 Pediatric Trauma Life Support Provider Manual – 3rd edition
 Pediatric Trauma Life Support Instructor Guide – 3rd edition
 ITLS Access Provider Manual – 2nd 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.
3
 Any late changes in course content may result in removal of course approval and nondelivery 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 -
Chapter -
$10.00 per student attending or enrolled
(There are no International fees for Instructor Recertifications.)
$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
4
.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.
5
.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
6
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
7
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
8
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:




.12
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
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:




.13
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
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.
9
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.
10
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.
11
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
12
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
1. Dr. Craig Carter
2. Jeanne Hosp
3. Beverly Jaco
4. Mark Hodges
5. Rockey Johnson
6. Ed Harber
7. Jim Williams
8. Daniel Carter
9. Roger Godbehere
10. Adam Peddicord
11. Barbara Sauter
Position
Chapter Medical Director
Chapter Coordinator
Chapter Executive Secretary
Eastern Region Representative
Louisville Region Representative
Northern Region Representative
South Central/ Bowling Green Region Representative
Western Region Representative
At-Large Representative
At- Large Representative
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.
II.
TWO MONTHS BEFORE THE COURSE
A.
III.
IV.
Create and distribute course advertisement ____
Order textbooks ____
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 ____
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.
VI.
VII.
DAY BEFORE THE COURSE
A.
Equipment placed in staging area ____
B.
Pre-course faculty meeting ____
C.
Arrange educational facility ____
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 ____
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
Date of Expiration: ______________
Other:
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
Lecture Assignment
Location
Course Coordinator
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
Excellent…………….……..Poor
LECTURES
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
Topic:
Overall knowledge
Excellent………………..….Unacceptable
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
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
4
3
2
1
Presentation of scenarios
4
3
2
1
Documentation
4
3
2
1
2. Skill Station
Topic:
3. Patient Assessment Stations
Topic:
Knowledge of objectives
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
Licenses / Certifications Held
Please attach a copy of each
_______ EMT – Basic
_______ EMT – Paramedic
_______ NO
_______ LPN
_______ RN
_______ ACLS
_______ PALS
_______ BTLS
_______ PHTLS
_______ TNCC
_______ CEN
_______ Other – Please List
___________________________
___________________________
___________________________
_____-_____-_____
Date Of Birth
STAFF USE ONLY
Instructor in Courses Verified:
Course Coordinator Courses Verified:
License/Certification in Good Standing:
License/Certification Current:
Letter of request Received:
Application Complete:
All Course Fees Current :
Affiliate Recommendation Letter(s):
Justification of Need Letter(s):
Two Year Length of Service Verified:
Scheduled for Meeting On:
Candidate Notified On:
Recommended for Provisional:
Monitor Date:
Affiliate Monitor:
Recommended for Final Appointment:
Medical Director Signature:
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
____ YES ____ NO
________________
________________
BY: _____________
____ YES ____ NO
________________
AT: _____________
________________
____ YES ____ NO
________________
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-XXLast 4 Digits Only
Home Address:
Work Address:
Home Phone:
Work Phone:
Fax Phone:
Email:
Affiliation:
Primary Specialty:
Board Certified:
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
Yes
No
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 #
DATE_____________________
PRACTICE_______
BASIC
TEST_______
ADVANCED
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
RAPID TRAUMA SURVEY
_____CHECK HEAD _____ DCAP_____TIC_____ BLS
_____CHECK NECK _____ DCAP_____TIC_____ BLS
_____CHECK FOR JVD_____TRACHEA DEVIATION
_____C-COLLAR APPLIED
_____CHECK CHEST_____DCAP(P) _____TIC_____ BLS
_____PERCUSSES (PRN)
_____CHECK BREATH SOUNDS _____CLEAR_____= OR NOT =
_____TRACHEA_____MIDLINE_____DEVIATED
_____CHEST_____DCAP(P) _____TIC_____BLS
_____LUNG SOUNDS_____CLEAR_____EQUAL_____UNEQUAL
_____PERCUSSES (PRN)
_____HEART SOUNDS_____CLEAR_____MUFFLED
_____IF INTUBATED, ET TUBE POSITION
_____ABDOMEN_____DCAP_____TIC_____BLS
_____PELVIS (IF NOT CHECKED IN PRIMARY)
_____DCAP_____ TIC_____BLS
_____CHECK HEART SOUNDS_____CLEAR_____MUFFLED
_____CHECK ABDOMEN_____DCAP_____TIC_____BLS
_____CHECK PELVIS_____DCAP_____TIC_____BLS
_____LEGS_____DCAP_____TIC_____BLS_____PMS_____ROM
_____ARMS_____DCAP_____TIC_____BLS_____PMS_____ROM
_____CHECK LOWER EXTREMITIES_____DCAP_____TIC
_____BLS_____PMS
_____CHECK UPPER EXTREMITIES_____DCAP_____TIC
_____BLS_____PMS
ONGOING ASSESSMENT
_____ASK PATIENT ABOUT CHANGES IN HOW HE FEELS
_____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
IF ALTERED MENTAL STATUS
=> DO BRIEF NEURO
_____PUPILS = OR NOT =, REACTIVE
_____GLASGOW COMA SCALE
_____SIGNS OF CUSHING RESPONSE
_____MEDICAL IDENTIFICATION DEVICES
_____SAMPLE HISTORY
_____VITAL SIGNS_____BP_____HR_____RESP
_____CHECK NECK (TRACHEA & VEINS)
_____CHECK CHEST (BREATH SOUNDS)
_____PERCUSSION (PRN)
_____CHECK ABDOMEN FOR TENDERNESS
_____FOCUSED ASSESSMENT FOR INJURIES
_____RECHECK ALL INTERVENTIONS
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