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

Primary Point of Contact - Contact Information

Trauma Program Manager - Contact Information

Same person as primary contact?*

Chief Nursing Officer - Contact Information

Trauma Medical Director - Contact Information

Survey Information

Request Type*
Trauma Designation Level or In Pursuit*
MM slash DD slash YYYY
Drop files here or
Accepted file types: pdf, jpg, png, Max. file size: 50 MB, Max. files: 5.

    For Level IV Surveys Only

    Do you perform trauma surgeries on-site?*
    Do you admit trauma patients to an on-site ICU?*
    Do you admit trauma patients with ISS of 15 or greater?*
    This field is for validation purposes and should be left unchanged.