Name of person filling out the form*Email of person filling out the form* Facility InformationTexas TQIP Membership Status*New MemberActive MemberTexas TQIP Confidentiality Agreement on file?*YesNoUnknownFacility*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?*YesNoN/ADate of first TQIP report Date Format: MM slash DD slash YYYY TQIP Report ID#(Will be kept confidential)Currently enrolled in PTQIP?*YesNoN/ADate of first PTQIP report Date Format: 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 Question
