FRCE Interest Form

Florida Regional Resuscitation Center of Excellence (FRCE) Interest Form

Thank you for your interest in becoming a Florida Regional Resuscitation Center of Excellence (FRCE). This initiative aims to enhance patient outcomes through a coordinated system of care for cardiac resuscitation. Please provide the following information to help us understand your hospital’s interest and readiness to participate. NOTE: FRCE designation is dependent on submission of an official FRCE letter of attestation signed by the hospital CEO and local EMS Medical Director.
Facility Information
Hospital/Facility Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Contact Information
Primary Contact Name*

First NameLast Name
Credentials
Job Title/Role*
Department (e.g., Emergency Medicine, Cardiology, Administration, etc.)*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Senior/Administrator CEO Contact Information

FRCE designation is dependent on submission of an official FRCE letter of attestation signed by the hospital CEO and local EMS Medical Director.
Senior Admin/CEO Name*

First NameLast Name
Senior Admin/CEO Email*
example@example.com

EMS Agency Information

FRCE designation is dependent on submission of an official FRCE letter of attestation signed by the hospital CEO and local EMS Medical Director.
EMS Agency Name*
If multiple local EMS Agencies transport patients to your hospital, list all agencies above. We will email you a customized letter of attestation based on the information provided here.
EMS Agency Name*
If multiple local EMS Agencies transport patients to your hospital, list all agencies above. We will email you a customized letter of attestation based on the information provided here.
EMS Medical Director*

First NameLast Name
EMS Medical Director Email*
example@example.com

Please leave comments, feedback, or describe any unique challenges or needs.
Please attach any additional information or documents that support your hospital's interest (optional).

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Next Steps:

Once your form is submitted, a member of the FRCE team will contact you to discuss your hospital's participation and the next steps in becoming a designated Resuscitation Center of Excellence.

Access the FRCE Tool Kit and Resources at www.faemsmd.org/FRCE if you have not done so already.
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Florida Regional Resuscitation Center of Excellence (FRCE) Interest Form