Stroke Survey Request

TETAF's credentialed and experienced surveyors provide consultative services for hospitals seeking Stroke Support Facility (Level III) designation. Services available include initial designation surveys, contingency surveys, and consultation surveys. Fill out the form below to request a survey.

PLEASE NOTE: If you do not receive a response within 24 hours contact Aaron Rogers at arogers@tetaf.org.

Survey Request - Stroke

"*" indicates required fields

Hospital Information

Facility Name*

Hospital Management Company/Owner*

Street Address*

City*

County*

State*

Zip Code*

Trauma Service Area*

Number of Licensed Beds*

Full Name of Tertiary Receiving Facility for Outgoing Stroke Transfers*

Primary Point of Contact - Contact Information

Name*

Title*

Phone Number*

Email*

Stroke Program Manager - Contact Information

Name*

Phone Number*

Email*

Stroke Medical Director - Contact Information

Name*

Phone Number*

Email*

Chief Nursing Officer - Contact Information

Name*

Phone Number*

Email*

Survey Request Information

Request Type*

Consultation

Designation Survey

Focused Survey

Type of Survey*

Initial Designation

Re-Designation

If this is a contingency survey, please upload your Texas Department of State Health Services (DSHS) determination letter here.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 50 MB, Max. files: 5.

Stroke Designation Expiration Date:

Date Required (For Use with Contingency Site Review Requests)

Preferred Four Week Survey Time Frame*

Has your facility previously used TETAF/Texas Perinatal Services for your survey needs?

Yes

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Name

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