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.

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* 1. Hospital:

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* 2. Designated or Non-Designated Stroke Facility?

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* 3. What level designation if answered yes to question 2?

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* 4. Is your facility a transfer facility or a receiving facility?

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* 5. Survey Completed By?

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* 6. Email:

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* 7. Phone Number:

PLEASE PRINT EACH PAGE!
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