Trauma Designation Request Form 2022

Trauma Designation Request Form

Bureau of Emergency Medical Services
Facility Requesting Designation*
Name of Hospital
Date of Request*

MonthDayYear
Date
Hospital Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trauma Program Manager (TPM)*

First NameLast Name
TPM Email*
example@example.com
TPM Phone Number*
Please enter a valid phone number.
Trauma Medical Director (TMD)*

First NameLast Name
TMD Email*
example@example.com
TMD Phone Number*
Please enter a valid phone number.
Hospital CEO/Administrator*

First NameLast Name
Hospital CEO/Administrator Email*
example@example.com
Hospital CEO/Administrator Phone*
Please enter a valid phone number.
Date of Most Recent Survey Visit (If applicable)

MonthDayYear
Date
Current Designation Expiration Date (If applicable)

MonthDayYear
Date
Desired Level of Trauma Center Designation*

Level ILevel IILevel IIILevel IV
Current Level of Trauma Center Designation*

Level ILevel IILevel IIILevel IVNot Designated

Please List 2 Weeks of Preferred Site Visit (Level III, Level IV)

	Month:	The Week of:
Week 1
Week 2

State of Utah Trauma Center Designation, Review, and Consultation Process

120 Days Prior to Survey:
- Submit Trauma Desgination Request Application
- First time applicants must have a minimum of 1 year of trauma registry data prior to application
90 Days Prior to Survey:
- State will provide site survey date
- Site agenda and reviewers names provided
- Details related to survey documents and details provided
30 Days Prior to Survey:
- Facility must submit completed Pre-Review Questionnaire (PRQ)
- Center must submit state required payment for site visit
  - Site visits cancelled or rescheduled within 30 days of the scheduled survey date will forefit the site vist fee.
30-60 Days Following Survey:
- State will send written report citing Strengths, Deficiencies, Opportunities for Improvement, and Recommendations that were cited during the site visit.
Trauma Center Files and Documents

ImageTrend:

Bureau of EMS Licensing & Certification System
State Trauma Documents PDF Files

Level III Documents:

*** SAMPLE*** UTAH LEVEL III TRAUMA CENTER APPLICATION 2024

UTAH LEVEL III TRAUMA CENTER STANDARDS 2024

Level IV Documents:

***SAMPLE*** UTAH LEVEL IV TRAUMA CENTER APPLICATION 2024

UTAH TRAUMA CENTER LEVEL IV DESIGNATION CRITERIA 2024

Trauma Site Review Documents Guide:

2024 Trauma Designation Readiness Document
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