CSTR Recertification Application - American Trauma Society

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CSTR Recertification Application

__________________________________________
First Name *
Last Name *
Employer
Title
Employer Address
Employer City
Employer State
Employer Zip
Home Address *
Home City *
Home State *
Home Zip *
Email Address *
Phone *
CSTR Number
Date of Original Certification
Date of Last Renewal
Reporting Continuing Education Hours Please list your continuing education hours below. If you have more than ten (10) continuing education certificates, please provide details on the first 10 in the spaces below then upload 1 PDF file containing *all* continuing education certificates at the bottom of this application. All continuing education hours must include date, program title/brief description of content, provider or sponsor, and number of contact/CE hours awarded. Recertification applications will be reviewed and approved by the ATS Trauma Registry and Data Council - CSTR Recertification Panel. The Panel reserves the right to request additional information or documentation to support the candidate’s application. Candidates will be notified of the application's outcome within three (3) weeks of submission. If criteria are deemed fulfilled, a new four-year certificate, effective the renewal date will be issued to the CSTR Renewal Candidate.
Course #1 - Date *
Course #1 - Title/Brief Description of Content *
Course #1 - Sponsoring Org. *
Course #1 - Contact Hours *
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Course #2 - Date
Course #2 - Title/Brief Description of Content
Course #2 - Sponsoring Org.
Course #2 - Contact Hours
_________________

Course #3 - Date
Course #3 - Title/Brief Description of Content
Course #3 Sponsoring Org.
Course #3 - Contact Hours
___________________

Course #4 - Date
Course #4 - Title/Brief Description of Content
Course #4 - Sponsoring Org.
Course #4 - Contact Hours
________________

Course #5 - Date
Course #5 - Title/Brief Description of Content
Course #5 - Sponsoring Org.
Course #5 - Contact Hours
_______________

Couse #6 - Date
Course #6 - Title/Brief Description of Content
Course #6 - Sponsoring Org.
Course #6 - Contact Hours
______________

Course #7 - Date
Course #7 - Title/Brief Description of Content
Course #7 - Sponsoring Org.
Course #7 - Contact Hours
____________

Course #8 - Date
Course #8 - Title/Brief Description of Content
Course #8 - Sponsoring Org.
Course #8 - Contact Hours
---------------

Course #9 - Date
Course 9 - Title/Brief Description of Content
Course #9 - Sponsoring Org.
Course #9 - Contact Hours
_______________________

Course #10 - Date
Course #10 - Title/Brief Description of Content
Course #10 - Sponsoring Org.
Course #10 - Contact Hours
______________________

CE Documentation UploadCertificates showing completion of the 32 required contact hours may be uploaded here. Please upload 1 PDF file that contains all certificates. If you would rather email them you may send them to: mriley@amtrauma.org.
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Signature *
Date *

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