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It specifies signed eligibility requirements, summaries of the trauma program, optional policy review frequency guidance, and variance/alternate pathway approval letters when applicable. It further details required documentation aligned to standards 1–6, including organizational governance items, licensure and accreditation evidence, capacity and transfer documentation, leadership resumes and continuing education, registry and PI plans, and supporting templates, letters, and guidelines for performance improvement.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/appendix-b-application-for-survey-attachment-and-report-list/375200/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/appendix-b-application-for-survey-attachment-and-report-list/375200.png","ImageObject",442,249,{"name":88,"@type":89},"Margaret","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-24",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What documents are required for the trauma program overview section?","Question",{"text":108,"@type":109},"The section requires a signed copy of the survey eligibility requirements and a summary of the trauma program. It also lists optional policy on review frequency and may require variance approval and alternate pathway approval letters when applicable.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is required under Standard 1: Commitment?",{"text":113,"@type":109},"Requirements include Board and Medical Staff resolution, PA Department of Health license evidence, Joint Commission or accrediting agency certification, an organizational chart for the trauma program relationship, and policies covering admission and trauma activation criteria including team activation timing and Emergency Medicine arrival expectations for Level IV centers.",{"name":115,"@type":106,"acceptedAnswer":116},"Which materials are needed for Standard 6: Performance Improvement?",{"text":117,"@type":109},"Standard 6 requires CVs for PI coordinators, PI coordinator job descriptions, a PIPS plan, and a committee attendance log template for the multidisciplinary peer review PI meeting. It also includes patient management guidelines covering areas such as fractures, cervical spine clearance, resuscitation management, DVT prophylaxis, and TBI management, with optional PI compliance tracking materials and PI project documentation.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},375200,1791623587,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Appendix B-APPLICATION FOR SURVEY ATTACHMENT AND REPORT LIST  \n\n| Trauma Program Overview | Signed copy of the survey eligibility requirements |\n| --- | --- |\n|  | Summary of the trauma program |\n|  | Does not require attachment to the AFS, but payer mix data is from Report Writer\u003Cbr>report = Core Measures and AFS Report |\n|  | Optional: Policy on the frequency of policy, guideline, job description review |\n|  | Variance Approval Letter (if applicable) |\n|  | Alternate Pathway Approval Letter (if applicable) |\n|  |  |\n| Standard 1: Commitment | Board and Medical Staff resolution |\n|  | PA Department of Health License |\n|  | The Joint Commission or Accrediting Agency for Acute Care Hospital's certificate of\u003Cbr>accreditation |\n|  | Organizational chart showing the relationship of the trauma program to the\u003Cbr>institution |\n|  | Policy(s) for admission of the trauma patient to the institution |\n|  | Policy(s) indicating the Trauma Activations Criteria, Minimal arrival time expectations for all level “team activations” including Trauma Consults when applicable, Role/duties for responding personnel, and arrival time expectations for the Emergency Medicine provider to trauma ED patients in Level IV center. |\n|  | Does not require attachment to the AFS, but ED Responses and alert level distribution data are from Report Writer report = Core Measures and AFS Report |\n|  | Report/Query from Report Writer: ‘Site Survey Report-Trauma Alert Upgrades’report for this reporting period to identify upgrades in trauma alerts |\n|  | Optional: Attachment describing who is responsible for airway management during\u003Cbr>the trauma resuscitation |\n|  | Optional: Attachment describing the role of the Emergency Department Attending and/or ED resident/AP in the resuscitative phase of care in the Trauma Resuscitation\u003Cbr>Area |\n|  | Level III and IV: Formal written agreement(s) with a Level I or II trauma center to\u003Cbr>provide on-going mentoring |\n|  |  |\n| Standard 2: Capacity and Ability | Does not require attachment to the AFS, but age distribution data is from Report Writer report = Core Measures and AFS Report |\n|  | Does not require attachment to the AFS, but transfers in and out data, and reason for transfers out data are from Report Writer report = Transfer Summary Statistics\u003Cbr>Report |\n|  | Does not require attachment to the AFS, but total PTOS cases transferred out (excluding pediatric and burn) data is from Report Writer report = Transfer\u003Cbr>Summary Statistics Report |\n|  | Report/Query from Report Writer: ‘Transfer In/Transfer Out (Double Transfer) Patient Data Report’ to demonstrate patients transferred into this trauma center from another hospital and then transferred out within 24 hours (aka double\u003Cbr>transfers) |\n\n\n|  | Total Number of Patients who double transferred data is from this report |\n| --- | --- |\n|  | If applicable the transfer plan and/or agreement for: Burn Patients, Cardiopulmonary Bypass, Hemodialysis Patients, Obstetric/Labor & Delivery Injured, Pediatric Patients, Spinal Cord Injured, and Other Specific Injured Populations |\n|  | Transfer plan and/or agreement with EMS to facilitate timely transportation for\u003Cbr>trauma patients requiring transfer out. |\n|  | Policy for formal consultation with institutions requesting transfer to this trauma\u003Cbr>center |\n|  | Policy explaining how the Emergency Department mobilizes resources for multiple simultaneous traumas (prior to activation of disaster plan) |\n|  | Policy(s) for Emergency Department diversion. This must include trauma\u003Cbr>diversion, CT diversion and neurosurgical diversion plans |\n|  | Hospital-Wide Disaster Plan |\n|  |  |\n| Standard 3: Trauma Program Medical Director | TPMD's CV |\n|  | TPMD job description |\n|  | TPMD continuing education for this survey cycle (Template Available) |\n|  | Institutional organization chart including the relationship between the TPMD, hospital governance, administration, nursing administration and other services |\n|  |  |\n| Standard 4: Trauma Pr","cbCaibjuZeo0arX8","https://ap.wps.com/l/cbCaibjuZeo0arX8","pdf",242895,8,"English","# Trauma Program Overview\n## Signed eligibility requirements and summary\n## Optional policy and approval letters\n# Standard 1: Commitment\n## Board and Medical Staff resolution and accreditation\n## Trauma activation criteria, admission, and arrival time expectations\n# Standard 2: Capacity and Ability\n## Transfers in/out and double-transfer patient data\n## Transfer plans for special populations and EMS coordination\n## ED mobilization and diversion policies; disaster plan\n# Standard 3: Trauma Program Medical Director\n## CV, job description, continuing education, and organizational chart\n# Standard 4: Trauma Program Manager\n## CV, job description, continuing education, and organizational chart\n# Standard 5: Registry\n## Trauma registry organizational chart and registrar job description\n# Standard 6: Performance Improvement\n## PI coordinator CVs, job descriptions, PIPS plan, committee log template\n## Patient management guidelines and optional PI compliance materials","[{\"question\":\"What documents are required for the trauma program overview section?\",\"answer\":\"The section requires a signed copy of the survey eligibility requirements and a summary of the trauma program. It also lists optional policy on review frequency and may require variance approval and alternate pathway approval letters when applicable.\"},{\"question\":\"What is required under Standard 1: Commitment?\",\"answer\":\"Requirements include Board and Medical Staff resolution, PA Department of Health license evidence, Joint Commission or accrediting agency certification, an organizational chart for the trauma program relationship, and policies covering admission and trauma activation criteria including team activation timing and Emergency Medicine arrival expectations for Level IV centers.\"},{\"question\":\"Which materials are needed for Standard 6: Performance Improvement?\",\"answer\":\"Standard 6 requires CVs for PI coordinators, PI coordinator job descriptions, a PIPS plan, and a committee attendance log template for the multidisciplinary peer review PI meeting. It also includes patient management guidelines covering areas such as fractures, cervical spine clearance, resuscitation management, DVT prophylaxis, and TBI management, with optional PI compliance tracking materials and PI project documentation.\"}]","Appendix B - Application for Survey Attachment and Report List | PDF",1790211848]