form test – TETAF

Name of person filling out the form*

Email of person filling out the form*

Facility Information

Texas 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 Level

Current 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 Status

Currently enrolled in TQIP?*

Yes
No
N/A

Date of first TQIP report

TQIP Report ID#

(Will be kept confidential)

Currently enrolled in PTQIP?*

Yes
No
N/A

Date of first PTQIP report

PTQIP Report ID#

(Will be kept confidential)

Trauma Medical Director

Name

Email

Number of years in TMD role?

Mobile Phone

Office Phone

Trauma Program Manager/Director

Name

First Last

Email

Number of years in TPM role?

Mobile Phone

Office Phone

Trauma Registrar

Name

First Last

Email

Number of years in TR role?

Mobile Phone

TR Office Phone

Alternate Member

Name

First Last

Email

Mobile Phone

Office Phone

Comment or Question

Facility Information

Trauma Center Level

(P) TQIP Status

Trauma Medical Director

Trauma Program Manager/Director

Trauma Registrar

Alternate Member

(512) 524-2892

(512) 524-2892

(512) 524-2892