Name of Hospital

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* 1. Name of Hospital

Physical Address

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* 2. Physical Address

Mailing Address

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* 3. Mailing Address

City

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* 4. City

Zip Code

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* 5. Zip Code

Hospital Administrator

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* 6. Hospital Administrator

Phone #

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* 7. Phone #

Fax #

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* 8. Fax #

Email Address

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* 9. Email Address

Administrator's Emergency Contact Number (24/7)

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

Trauma Coordinator

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* 11. Trauma Coordinator

Phone #

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* 12. Phone #

Fax #

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* 13. Fax #

Email

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* 14. Email

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

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

ED  Medical Director:

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* 16. ED  Medical Director:

Phone #

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* 17. Phone #

Fax #

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* 18. Fax #

Email

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* 19. Email

ED Medical Directors Emergency Contact Number (24/7)

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

RAC Representative

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* 21. RAC Representative

Phone #

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* 22. Phone #

Phone # that can receive text messages for reminders

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

Fax #

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* 24. Fax #

Email

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* 25. Email

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

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

RAC Alternate Representative

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* 27. RAC Alternate Representative

Phone #

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* 28. Phone #

Fax #

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* 29. Fax #

Email

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* 30. Email

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

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

Tax status of Hospital

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* 32. Tax status of Hospital

Phone Number for on-line Medical Control

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* 33. Phone Number for on-line Medical Control

Radio Frequency for on-line Medical Control:

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

Number of Licensed Hospital Beds

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* 35. Number of Licensed Hospital Beds

Number of Emergency Room Beds: 

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* 36. Number of Emergency Room Beds: 

Number of Intensive Care Beds: 

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* 37. Number of Intensive Care Beds: 

Do you have designated ICU beds for Pediatric patients

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

If yes, how many beds are designated for Pediatric patients

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

Are you a designated Trauma Facility

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* 40. Are you a designated Trauma Facility

Trauma Designation Level

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* 41. Trauma Designation Level

If you are not a designated facility, are you seeking trauma designation

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

If yes, what level are you seeking?

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

Do you have a Trauma Registry

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* 44. Do you have a Trauma Registry

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

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

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

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

What is your average ISS?

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* 47. What is your average ISS?

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

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

Why?

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* 49. Why?

Who provides 24 hour coverage in your ER?

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

How many physicians are certified in ATLS

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* 51. How many physicians are certified in ATLS

How many physicians need certification in ATLS

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* 52. How many physicians need certification in ATLS

How many nurses are TNCC certified

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* 53. How many nurses are TNCC certified

How many nurses are seeking TNCC certification

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* 54. How many nurses are seeking TNCC certification

How many nurses are ENPC certified

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* 55. How many nurses are ENPC certified

How many nurses are seeking ENPC certification

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* 56. How many nurses are seeking ENPC certification

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

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

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

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

If no, please explain in detail

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* 59. If no, please explain in detail

Describe in detail any injury prevention programs used in your institution:

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

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

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

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?

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* 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?

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

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* 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

Do you have a plan to obtain this EQUIPMENT?

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

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

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

Do you have a plan to obtain his EDUCATION?

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

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

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

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

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

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