Next Generation - Acute Care Trauma Registry Account
Please complete the information below requesting the following person(s) be added as an Administrator for your trauma center in the Next Generation Trauma Registry (NGTR). Please complete the form and email a signed copy to the contacts listed below. As an Administrator, your role will be to add/delete, grant and maintain users’ access in the NGTR on behalf of your hospital.
Please print
Hospital Name: _________________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________
Phone: _________________________________________________________________
Administrator
Name: _____________________________________
Title: _____________________________________
Phone: __________________________ __________ Ext. _ __
Email: _____________________________________
Contact 1 Signature __________________________________________ ______________
Date
Trauma Registrar Contact-
Name: _____________________________________
Title: _____________________________________
Phone: __________________________ __________ Ext. _ __
Email: _____________________________________
List all additional email(s)(up to seven) who should receive notifications regarding any submissions or reports status. Administrators will be included in the distribution list.
___________________________________ __
____________________________________ _
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For Internal use.
Date account set up and Administrator notified: _______________________________
Signed: _______________________________________
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For questions, please contact: Joshua Sturms, OPS Information Techology Analyst
(850) 245-4440 ext. 2836
or
Carma Harvey, Information Technology Analyst
(850) 245-4440 ext. 2731
3G TR 33901 V300 (199907) 3RD GENERATION PARTNERSHIP PROJECT
3G TS 23057 V1230 (19990708) TECHNICAL SPECIFICATION 3RD GENERATION
3GPP TR 32826 V100 (200912) TECHNICAL REPORT 3RD GENERATION
Tags: account please, date account, acute, generation, trauma, registry, account, please