STEMI RAC Data Collection - Qtr. (1 & 2) 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 January 1, 2016, through June 30, 2016 - 1st and 2nd Quarter. We appreciate your input and participation in this program. Question Title * 1. Hospital: Question Title * 2. What level designation if answered yes to question 2? Question Title * 3. Is your facility a transfer facility or a receiving facility? STEMI Receiving Facility STEMI Transfer Facility Both Other (please specify) Question Title * 4. Survey Completed By? Question Title * 5. Email: Question Title * 6. Phone Number: PLEASE PRINT EACH PAGE! Next