Free Trauma Care Facility Classification, dph 7479 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7479 (12/04)

STATE OF WISCONSIN Bureau of Local Health Support and Emergency Medical Services Page 1 of 2

TRAUMA CARE FACILITY CLASSIFICATION / DESIGNATION APPLICATION
Instructions on page 2

Section A. LEVEL OF CLASSIFICATION / DESIGNATION Name of Hospital to appear on Certificate Hospital is applying for the following classification / designation: Level I Level II Level III Level IV Unclassified

Initial Classification / designation Section B. FACILITY IDENTIFYING INFORMATION Facility Name Mailing Address (include street address) City Trauma Medical Director Name and Title Email

Re-classification / designation

Telephone Number State Zip County

Telephone Number (include area code)

Fax Number

Trauma Program Coordinator / Manager Name and Title Email Telephone Number Fax Number

Physician Director of Emergency Medicine Email Telephone Number Fax Number

Chief Executor Officer or Administrator Name and Title Email Contact Person Name and Title Email Telephone Number Fax Number Telephone Number Fax Number

Section C. NAME OF REGIONAL TRAUMA ADVISORY COUNCIL (RTAC)

Section D. ACKNOWLEDGEMENT AND SIGNATURE(S) In accordance with the requirements of the Trauma System Administrative Rules, HFS 118, Insert Name of Hospital agrees to abide by the ACS Verification Standards and/or the State Classification / Designation Criteria.
Or

Insert Name of Hospital chooses not to be an ACS Verified or State Classified trauma facility and therefore is not part
of the Trauma System and shall be considered an "Unclassified hospital." Signature of CEO Date Signed

DPH 7479 (12/04)

Page 2 of 2

INSTRUCTIONS FOR COMPLETING THE TRAUMA CARE FACILITY CLASSIFICATION / DESIGNATION APPLICATION In accordance with State Statute 146, all hospitals in Wisconsin that wish to participate in the trauma system must determine their classification / designation. Even though all hospitals are encouraged to apply for state classification / designation as a trauma center, participation remains voluntary. Any hospital that chooses not to participate in the trauma system must select "Unclassified" on the application. If "Unclassified" is selected complete Section A, Section B Facility Name and Address only and Section D of this application. Complete all sections of the application that apply, do not leave any blank spaces. Blank spaces on the application may be interpreted as an incomplete application. The application may be completed on a personal computer or printed and completed by hand. Print clearly or type. This is a Microsoft Word document and requires that the user also have Microsoft Word in order to complete it online. If completing the application online follow the steps below: · · · Use the `Tab' key to move through the form. Type responses in shaded fields. When you have completed this document, save your work on your personal computer.

Only the completed, printed, signed, application will be accepted and should be mailed to the address listed at the bottom of this page. DO NOT FAX OR EMAIL.
Section A. LEVEL OF CLASSIFICATION / DESIGNATION Indicate whether the hospital is applying for classification / designation as a Level I, II, III or IV or Unclassified. If the facility is applying for a Level I or II, please submit a copy of the American College of Surgeons ­ Committee on Trauma (ACS-COT) Certificate of Verification or a letter of successful verification from the ACS. If the facility is applying for Level III or IV and has been ACS verified, please submit a copy of the ACS-COT Certification of Verification. Indicate whether this is an original classification / designation or a re-classification / designation. If your hospital is already ACS verified, but this is an original classification / designation with the State of Wisconsin please check the "initial classification / designation" box. Section B. FACILITY IDENTIFYING INFORMATION Type the identifying information of the hospital as it should appear on the classification / designation certificate. Include the area code with the telephone number. Include the city and zip code. Include the trauma program manager or the name of person who fulfills those duties. Provide the name and telephone number of the person to contact for questions about the application and the assessment and classification / designation criteria. Section C. NAME OF REGIONAL TRAUMA ADVISORY COUNCIL (RTAC) Select the RTAC with which the hospital has membership: RTACs include West Central, North / Northwest, North Central, Lake Superior, Northeast, Fox Valley, Southeast, South Central and Southwest
. N

Section D. ACKNOWLEDGEMENT AND SIGNATURE (S) Type in the name of the hospital in the shaded space provided. Indicate whether the hospital chooses not to be an ACS Verified or State Classified trauma facility. The application must be signed and the dated as indicated before submitting. NOTE: Questions regarding the classification / designation process and the trauma system are anticipated. There are resources available to assist your facility. In addition to the State Trauma Coordinator listed below, Wisconsin has nine Regional Trauma Advisory Councils which meet on a regular basis. Attending the RTAC meetings is the best resource to remain current of the state trauma system. The State Trauma Advisory Council (STAC) meets on a regular basis. To find out more information on RTACs and STAC please contact the State Trauma Coordinator listed below or go to the Department of Health and Family Services, Bureau of Local Health Support and Emergency Medical Services Webpage www.dhfs.wisconsin.gov/ems Mail the completed application, assessment and classification / designation criteria (if applicable) to: Bureau of Local Health Support and EMS Attn: State Trauma Care System Coordinator, Room 118 PO Box 2659 Madison, Wisconsin 53701-2659 For questions contact: Marianne Peck RN, MSN, State Trauma Care System Coordinator (608) 266-0601 [email protected]