Hospital Needs Assessment Question Title * 1. Name of Hospital Question Title * 2. Physical Address Question Title * 3. Mailing Address Question Title * 4. City Question Title * 5. Zip Code Question Title * 6. Hospital Administrator Question Title * 7. Phone # Question Title * 8. Fax # Question Title * 9. Email Address Question Title * 10. Administrator's Emergency Contact Number (24/7) Question Title * 11. Trauma Coordinator Question Title * 12. Phone # Question Title * 13. Fax # Question Title * 14. Email Question Title * 15. Trauma Coordinator's Emergency Contact Number (24/7) Question Title * 16. ED Medical Director: Question Title * 17. Phone # Question Title * 18. Fax # Question Title * 19. Email Question Title * 20. ED Medical Directors Emergency Contact Number (24/7) Question Title * 21. RAC Representative Question Title * 22. Phone # Question Title * 23. Phone # that can receive text messages for reminders Question Title * 24. Fax # Question Title * 25. Email Question Title * 26. RAC Representative's Emergency Contact Number (24/7) Question Title * 27. RAC Alternate Representative Question Title * 28. Phone # Question Title * 29. Fax # Question Title * 30. Email Question Title * 31. RAC Alternate Representative's Emergency Contact Number (24/7) Question Title * 32. Tax status of Hospital Question Title * 33. Phone Number for on-line Medical Control Question Title * 34. Radio Frequency for on-line Medical Control: Question Title * 35. Number of Licensed Hospital Beds Question Title * 36. Number of Emergency Room Beds: Question Title * 37. Number of Intensive Care Beds: Question Title * 38. Do you have designated ICU beds for Pediatric patients Yes No Question Title * 39. If yes, how many beds are designated for Pediatric patients Question Title * 40. Are you a designated Trauma Facility Yes No Question Title * 41. Trauma Designation Level I II III IV Question Title * 42. If you are not a designated facility, are you seeking trauma designation Yes No Question Title * 43. If yes, what level are you seeking? I II III IV Question Title * 44. Do you have a Trauma Registry Yes No Question Title * 45. How many trauma patients do you see in your ER in a 12 month period? Question Title * 46. How many trauma admissions do you have in a 12 month period Question Title * 47. What is your average ISS? Question Title * 48. When considering transfer of a trauma patient, what facility are you most likely to transfer to? Question Title * 49. Why? Question Title * 50. Who provides 24 hour coverage in your ER? MD PA NP Question Title * 51. How many physicians are certified in ATLS Question Title * 52. How many physicians need certification in ATLS Question Title * 53. How many nurses are TNCC certified Question Title * 54. How many nurses are seeking TNCC certification Question Title * 55. How many nurses are ENPC certified Question Title * 56. How many nurses are seeking ENPC certification Question Title * 57. Please indicate the types of services your facility can provide for a trauma patient: General Surgery Orthopedic Surgery Facial Reconstruction Spine Neurosurgery Surgery Neurology Question Title * 58. Of the services you circled, do they provide coverage 24 hours per day Yes No Question Title * 59. If no, please explain in detail Question Title * 60. Describe in detail any injury prevention programs used in your institution: Question Title * 61. Describe in detail, issues your facility has identified that would improve trauma care in your facility: Question Title * 62. RAC-D can offer assistance to its members through RAC wide projects to meet common needs. It can also offer advice and assistance in carrying out injury prevention activities. With this in mind:How can the RAC assist your facility to improve trauma care? Question Title * 63. RAC-D can offer assistance to its members through RAC wide projects. It can also offer advice and assistance in carrying out injury prevention activities. With that in mind please list your needs below:Please list EQUIPMENT needed in order or priority Question Title * 64. Do you have a plan to obtain this EQUIPMENT? Question Title * 65. Please list EDUCATION needed (include course , training equipment and # of students needing training) Question Title * 66. Do you have a plan to obtain his EDUCATION? Question Title * 67. Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience) Question Title * 68. Use the space below to provide details concerning your needs and how the RAC might assist you: Done
