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Pretesting 29 March 2018 and Instructor Course 30 March 2018

Winfield, IL (Northwestern Central DuPage Hospital)

NOTE: Onlyfully completed applications will be considered. Applications will be accepted until the course is full.

All Instructor Potentials must confirm their attendance 4 weeks prior to the courseto allow those on the waiting list the opportunity to plan and receive materials in the event there is an opening.

Application deadline: __ 9 February 2018______

Send to:AMITA St. Alexius Medical Center

ATTN: EMS/Trauma Department Karin Buchanan

1555 Barrington Road

Hoffman Estates, IL 60196

Applicant Name:______

Address:______

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Preferred Phone 1 (Cell/Home/Work [circle one]): ______/ ______—______

Preferred Phone 2 (Cell/Home/Work [circle one]): ______/ ______—______

Preferred Email 1 (Home/Work [circle one]):______

Preferred Email 2 (Home/Work [circle one]):______

RN License No/State:______

Date of Provider Course Attended:______

Course Director:______

Location ofProvider Course:______

PLEASE INCLUDE THE FOLLOWING WITH YOUR APPLICATION:

□Copy current nursing license

□Copy current TNCC provider card

□Letter indicating instructor potential from Provider Course Director (the Course Director of the course you received your provider card). No other Recommendation letter will be considered in lieu of the Provider Course Director instructor potential letter

□TNCC INDIVIDUAL PERFORMANCE REPORT PROVIDER COURSE (form filled out by course director with test score, TNP, participated in spinal/airway, have/have not passed course)

□Letter supporting your potential to be a successful instructor (may be written by a professional colleague)

□TNCC Instructor Potential Content Expertise Form

□Name of possible instructor mentor

□Course fee $ (DO NOT SEND AT THIS TIME)

1. Employment Experience (please list current position first and include dates of employment):______

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2. Professional Experience (particularly related to trauma):______

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3. Education (basic preparation through highest degrees held):______

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4. Continuing Education offerings attended in the last 2 years:______

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5. Continuing Educationofferings presented in the last 2 years:______

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6. Provide a statement expressing commitment to and interest in teaching future TNCC courses: ______

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Notification of acceptance into the instructor course will occur by February12 via email. Instructions, assignments, and hotel information will be sent with that email. Do not send checks with this application. Pre Course and Course will be held at

Northwestern Central DuPage Hospital

Main Entrance/Bed Tower Conference Rooms

25 North Winfield Road

Winfield, IL 60190

Please forward the application to:

Karin Buchanan

AMITA Health St. Alexius Medical Center

1555 Barrington Road

Attn: EMS/Trauma Department

Hoffman Estates, IL 60196

Or fax to 847-781-3913, attention Karin Buchanan, or e-mail scanned documents to Karin at

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Emergency Nurses Association 915 Lee St, Des Plaines, IL 60016 Course Operations: 800.942.0011 Email: Revision Date:September 2016