Name of person filling out the form* Email of person filling out the form* Facility InformationTexas TQIP Membership Status* New Member Active Member Texas TQIP Confidentiality Agreement on file?* Yes No Unknown Facility* Healthcare System Affiliation* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Trauma Center LevelCurrent Trauma Level* Level I - Adult Level I - Pediatrics Level II - Adult Level II - Pediatrics Level III Level IV In Active Pursuit Level I - Adult Level I - Pediatrics Level II - Adult Level II - Pediatrics Level III Level IV (P) TQIP StatusCurrently enrolled in TQIP?* Yes No N/A Date of first TQIP report MM slash DD slash YYYY TQIP Report ID# (Will be kept confidential)Currently enrolled in PTQIP?* Yes No N/A Date of first PTQIP report MM slash DD slash YYYY PTQIP Report ID# (Will be kept confidential)Trauma Medical DirectorName First Last Email Number of years in TMD role? Mobile PhoneOffice PhoneTrauma Program Manager/DirectorName First Last Email Number of years in TPM role? Mobile PhoneOffice PhoneTrauma RegistrarName First Last Email Number of years in TR role? Mobile PhoneTR Office PhoneAlternate MemberName First Last Email Mobile PhoneOffice PhoneComment or QuestionCAPTCHA
