Maternal Survey Request Form

Hospital Information

Facility Name *

Street Address *

City *

County *

State *

Zip Code *

Hospital Management Company/Owner *

Total Number of Licensed Hospital Beds *

Perinatal Care Region *

Primary Point of Contact - Contact Information

Primary Point of Contact Name *

Primary Point of Contact Title *

Primary Point of Contact Phone Number *

Primary Point of Contact Email *

Maternal Medical Director Contact Information

Maternal Medical Director Name *

Maternal Medical Director Phone Number *

Maternal Medical Director Email *

Maternal Physician Employer *

Maternal Program Manager Contact Information

Maternal Program Manager Name *

Maternal Program Manager Phone Number *

Maternal Program Email *

Chief Nursing Officer Contact Information

Chief Nursing Officer Name *

Chief Nursing Officer Phone Number *

Chief Nursing Officer Email *

Survey Information

Request Type *

Maternal Consultation
Maternal Designation
Maternal Focused Survey

Maternal Care Designation Level or In Pursuit *

Designation expiration date *

Preferred Four Week Survey Time Frame *

Enter 4 weeks in which hospital administration and maternal program teams will be available. (Examples: June -or- June 15 to July 15 -or- July 20-30; August 5-10; August 15-30)

Has your facility previously utilized TETAF/Texas Perinatal Services for your survey needs? *

Annual Obstetric Statistics

Number of Live Births*

Number of Multiple Births *

Maternal Transfers Out to Higher Level of Care *

Maternal Transfers in from Lower Level of Care *

Full Name of Tertiary Receiving Facility for Outgoing Maternal Transfers *

Comment

Maternal Survey Request Form

Maternal Survey Request Form

Hospital Information

Primary Point of Contact - Contact Information

Maternal Medical Director Contact Information

Maternal Program Manager Contact Information

Chief Nursing Officer Contact Information

Survey Information

Annual Obstetric Statistics

Christus Santa Rosa Hospital San Marcos

Methodist Children’s Hospital

Knapp Medical Center

San Angelo Community Medical Center

Valley Regional Medical Center

Southwest General Hospital

Ascension Seton

Ascension Providence

The Hospitals of Providence Children’s Hospital El Paso

Maternal Survey Request Form

Hospital Information

Primary Point of Contact - Contact Information

Maternal Medical Director Contact Information

Maternal Program Manager Contact Information

Chief Nursing Officer Contact Information

Survey Information

Annual Obstetric Statistics

Christus Santa Rosa Hospital San Marcos

Methodist Children’s Hospital

Knapp Medical Center

San Angelo Community Medical Center

Valley Regional Medical Center

Southwest General Hospital

Ascension Seton

Ascension Providence

The Hospitals of Providence Children’s Hospital El Paso

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