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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 2nd 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 1st 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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