Stroke RAC Data Collection - (Qtr. 3 & 4) 2016 Administrative Information This information goes directly to the RAC-G office as CONFIDENTIAL! Please answer the questions on each page and PRINT copy BEFORE you hit "DONE". With any questions or comments please email kelby@rac-g.org or call the RAC-G office at 903-593-4722 for information.This form covers data spanning between July 1, 2016, through December 31, 2016 - 3rd and 4th Quarter. We appreciate your input and participation in this program. Question Title * 1. Hospital: Question Title * 2. Hospital County: Question Title * 3. Urban or Rural Hospital: Urban Rural Question Title * 4. Designated or Non-Designated Stroke Facility? Question Title * 5. What level of Stroke Designation is your facility? Question Title * 6. Is your facility a transfer facility or a receiving facility? Receiving Facility Transfer Facility Other (please specify) Question Title * 7. Survey Completed By? Question Title * 8. Email: Question Title * 9. Phone Number: Next