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 (July 1, 2015 and December 31, 2015) 3rd and 4th Quarter data.

We appreciate your input and participation in this program. As soon as you submit we will respond back with a conformation of receipt. 

Question Title

* 1. Hospital:

Question Title

* 2. Designated or Non-Designated Stroke Facility?

Question Title

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

Question Title

* 4. Survey Completed By?

Question Title

* 5. Email:

Question Title

* 6. Phone Number:

PLEASE PRINT EACH PAGE!

T