HOTRAC Member Information (2018)

1. Member

14% of survey complete.

This survey may be used as the annual Member Information Sheet that has been collected in previous years. All HOTRAC members are required to complete this information in order to remain in good standing. If a question does not apply to you or your entity(i.e. Medical Director Information, Education or Injury Prevention Program, etc.) please mark the question with an N/A. Once you begin the survey you will need to complete it during the same session. If you have any questions, comments, or concerns, please feel free to contact HOTRAC Staff.

Question Title

* 1. Member Information

Entity/Individual Name: *

Name of Person Completing this Survey: *

Phone Number of Person Completing: *

Address:

City/Town: *

State: *

ZIP: *

Phone Number: *

Fax Number: *

Question Title

* 2. Member Type

Hospital - $35/bed plus $1000 per designation/accreditation/designation

9-1-1 Ground EMS - $300 base plus $150 per truck over 1

Other Healthcare Providers (Freestanding EDs, Clinics, Physicians Offices, etc.)

Air Providers - $750

Other (FRO, City, County, etc.) - $175

Individual - $50

Question Title

* 1. Member Information

Question Title

* 2. Member Type

Question Title

* 3. If any demographic information about your entity has changed, please enter below. (examples: licensed beds, licensed trucks, CT capability, etc.)