* 1. Name of Hospital

* 2. Physical Address

* 3. Mailing Address

* 4. City

* 5. Zip Code

* 6. Hospital Administrator

* 7. Phone #

* 8. Fax #

* 9. Email Address

* 10. Administrator's Emergency Contact Number (24/7)

* 11. Trauma Coordinator

* 12. Phone #

* 13. Fax #

* 14. Email

* 15. Trauma Coordinator's Emergency Contact Number (24/7)

* 16. ED  Medical Director:

* 17. Phone #

* 18. Fax #

* 19. Email

* 20. ED Medical Directors Emergency Contact Number (24/7)

* 21. RAC Representative

* 22. Phone #

* 23. Phone # that can receive text messages for reminders

* 24. Fax #

* 25. Email

* 26. RAC Representative's Emergency Contact Number (24/7)

* 27. RAC Alternate Representative

* 28. Phone #

* 29. Fax #

* 30. Email

* 31. RAC Alternate Representative's Emergency Contact Number (24/7)

* 32. Tax status of Hospital

* 33. Phone Number for on-line Medical Control

* 34. Radio Frequency for on-line Medical Control:

* 35. Number of Licensed Hospital Beds

* 36. Number of Emergency Room Beds: 

* 37. Number of Intensive Care Beds: 

* 38. Do you have designated ICU beds for Pediatric patients

* 39. If yes, how many beds are designated for Pediatric patients

* 40. Are you a designated Trauma Facility

* 41. Trauma Designation Level

* 42. If you are not a designated facility, are you seeking trauma designation

* 43. If yes, what level are you seeking?

* 44. Do you have a Trauma Registry

* 45. How many trauma patients do you see in your ER in a 12 month period? 

* 46. How many trauma admissions do you have in a 12 month period

* 47. What is your average ISS?

* 48. When considering transfer of a trauma patient, what facility are you most likely to transfer to?

* 49. Why?

* 50. Who provides 24 hour coverage in your ER?

* 51. How many physicians are certified in ATLS

* 52. How many physicians need certification in ATLS

* 53. How many nurses are TNCC certified

* 54. How many nurses are seeking TNCC certification

* 55. How many nurses are ENPC certified

* 56. How many nurses are seeking ENPC certification

* 57. Please indicate the types of services your facility can provide for a trauma patient:

* 58. Of the services you circled, do they provide coverage 24 hours per day

* 59. If no, please explain in detail

* 60. Describe in detail any injury prevention programs used in your institution:

* 61. Describe in detail, issues your facility has identified that would improve trauma care in your facility:

* 62. RAC-D can offer assistance to its members through RAC wide projects to meet common needs. It can also offer advice and assistance in carrying out injury prevention activities. With this in mind:

How can the RAC assist your facility to improve trauma care?

* 63. RAC-D can offer assistance to its members through RAC wide projects. It can also offer advice and assistance in carrying out injury prevention activities. With that in mind please list your needs below:
Please list EQUIPMENT needed in order or priority

* 64. Do you have a plan to obtain this EQUIPMENT?

* 65. Please list EDUCATION needed (include course , training equipment and # of students needing training)

* 66. Do you have a plan to obtain his EDUCATION?

* 67. Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience)

* 68. Use the space below to provide details concerning your needs and how the RAC might assist you:

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