emssurvey

Fox Valley Regional Trauma Advisory Council

Emergency Medical Services Information Survey

Dear EMS associate,

The Fox Valley Regional Trauma Advisory Council (RTAC) has been meeting since October 2002. The goal of the RTAC is to improve the care of the trauma patient in the Fox Valley and surrounding areas. An executive council consisting of 14 members has been elected and includes representation from pre-hospital and hospital personnel as well as community health personnel. Representatives are equally divided between rural and urban care providers.

The purpose of the attached survey is to determine the emergency medical service capabilities throughout the areas served by the Fox Valley RTAC. We would appreciate your assistance in obtaining this information. In addition, we would like to encourage members of your service to become involved in the RTAC. The RTAC consists of 4 subcommittees that meet monthly prior to the full RTAC meeting. The subcommittees are: Injury Prevention & Education, Medical Oversight, Performance & Improvement, and Specialty Care. Meetings of the subcommittees are held monthly on the 2^nd Wednesday of the month at 6 pm, the full meeting follows at 7 pm. Locations vary. For more information please go to: www.thedacare.org/trauma and select the Regional Trauma Advisory Council link or you may call Kelly Stanislaus, RTAC Secretary, at 920-729-3347.

Please complete this survey and return by July 15, 2003 to:

Kelly Stanislaus, RN, Trauma Coordinator

Theda Clark Medical Center

130 Second Street, PO Box 2021

Neenah, WI 54957-2021

E-Mail: Kelly.stanislaus@thedacare.org

If you have any questions regarding this survey, please e-mail jeff.grimm@thedacare.org or call me at 920-729-2114. Thank you in advance for your assistance.

Sincerely,

Jeff Grimm, RN, EMT-P

Co-chairperson, Medical Oversight Committee

Fox Valley RTAC.

Fox Valley Regional Trauma Advisory Council

Emergency Medical Services Survey

All EMS agencies must register a primary RTAC selection with the State. To do so or if you have questions about the State Trauma Advisory Council (STAC) or which RTAC would be appropriate for your service, please contact:

Marianne Peck, RN, MSN

WI Statewide Trauma System Coordinator

Bureau of EMS & Injury Prevention

Division of Public Health

PO Box 2659

Madison, WI 53701-2659

(608) 266-0601

Fax: (608) 261-6392

E-mail: peckme@dhfs.state.wi.us

Has your service chosen a primary RTAC? Yes / No
If yes, please circle the primary RTAC that you have chosen

For your information, you may chose to affiliate with more than 1 RTAC but you must register your choice of a primary RTAC with the state.

Northeast RTAC Fox Valley RTAC Southeast RTAC

Southcentral RTAC Southwest RTAC North/Northwest RTAC

West Central RTAC Lake Superior RTAC North Central RTAC

Would you like to be on the Fox Valley RTAC Mailing List? Yes / No
If Yes, Please include contact information including phone number and e-mail address. A business card is acceptable.
Please circle the level(s) of service that your agency provides.

FIRST RESPONDER EMT-B EMT-IV TECH

EMT-I EMT-IE EMT-P

OTHER: _________________________

Please provide a primary contact person at your service for us to relay RTAC information to.

NAME: ___________________________________________

TITLE: ___________________________________________

AGENCY: _________________________________________

ADDRESS: ________________________________________

CITY: ____________________________________________

PHONE: ____________________ FAX: ________________________

E-MAIL: ______________________________________________________

Please list your service medical director.

NAME: ___________________________________________

TITLE: ___________________________________________

AGENCY: _________________________________________

ADDRESS: ________________________________________

CITY: ____________________________________________

PHONE: ____________________ FAX: ________________________

E-MAIL: ______________________________________________________

Please list your primary destination hospital(s)

_____________________________________________________________________________________________________________________________________________________________________________________________

Please list your medical control hospital(s)

_____________________________________________________________________________________________________________________________________________________________________________________________

Please list any 1^st Responder Groups affiliated with your service and contact information for the groups. (Please list on a separate sheet if necessary).

AGENCY: _________________________________________

NAME: ___________________________________________

TITLE: ___________________________________________

ADDRESS: ________________________________________

CITY: ____________________________________________

PHONE: ____________________ FAX: ________________________

E-MAIL: ______________________________________________________

AGENCY: _________________________________________

NAME: ___________________________________________
TITLE: ___________________________________________
ADDRESS: ________________________________________
CITY: ____________________________________________
PHONE: ____________________ FAX: ________________________
E-MAIL: ______________________________________________________
Please list any services that your agency has mutual aid agreements with. (Please list on a separate sheet if necessary)

AGENCY: _________________________________________

NAME: ___________________________________________
TITLE: ___________________________________________
ADDRESS: ________________________________________
CITY: ____________________________________________
PHONE: ____________________ FAX: ________________________
E-MAIL: ______________________________________________________

AGENCY: _________________________________________

NAME: ___________________________________________
TITLE: ___________________________________________
ADDRESS: ________________________________________
CITY: ____________________________________________
PHONE: ____________________ FAX: ________________________
E-MAIL: ______________________________________________________
Do you currently transport/transfer critically injured trauma patients to an ACS (American College of Surgeons) Verified Level I or Level II trauma center? Yes / No
If yes, please circle any American College of Surgeons (ACS) Verified Level I or II Trauma Centers in WI that you transport patients to.

Froedert Memorial Hospital, Milwaukee: Level I

UW Hospital, Madison: Level I

Theda Clark Medical Center, Neenah Level II

St. Vincent’s Hospital, Green Bay Level II

Luther Hospital, Eau Claire Level II

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