Trauma Survey Request

Hospitals are evaluated for Trauma Center Designation requirements, as defined by Texas Administrative Code 157.125. 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 - Trauma

"*" 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 Trauma Transfers*

Primary Point of Contact - Contact Information

Name*

Title*

Phone Number*

Email*

Trauma Medical Director - Contact Information

Name*

Phone Number*

Email*

Trauma Program Manager - Contact Information

Name*

Phone Number*

Email*

Chief Nursing Officer - Contact Information

Name*

Phone Number*

Email*

Survey Information

Request Type*

Consultation

Designation Survey

Focused

Type of Survey*

Initial Designation

Re-Designation

Trauma Designation Level or In Pursuit*

III

Is this a contingency site review?*

Yes

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

Drop files here or

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

Date required (For use with contingency site review requests)

MM slash DD slash YYYY

Trauma Designation Expiration Date*

MM slash DD slash YYYY

Number of Trauma Admissions to Facility*

Preferred Four Week Survey Time Frame*

Does your facility have the following:

OR capabilities

ICU capabilities

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

Yes

Who was your last surveyor(s)?

For Level IV Surveys Only

Do you perform trauma surgeries on-site?

Yes

Do you receive trauma transfers?

Yes

Annual trauma cases from ER to OR:

If trauma cases from ER to OR are > 0, please list all trauma-related surgery types performed on-site:

Annual trauma cases from ER to ICU (ISS ≥ 9):

Comments

This field is for validation purposes and should be left unchanged.