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ARIZONA STATE TRAUMA REGISTRY DATA REQUEST FORM

ARIZONA STATE TRAUMA REGISTRY DATA REQUEST FORM

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Of Health Services Bureau of EMS Trauma System Attn Trauma Data Administrator 150 N. 18th Avenue Suite 540 Phoenix AZ 85007-3248 Phone 602 542-1245 Fax 602 364-3568 REPORTING FACILITY INFORMATION Facility Name Facility Address DATA SUBMISSION INFORMATION Date data entry completed in the web registry for the quarter ASTR Quarter Reporting Quarter Year Number of Records Case Date Range Applied to this Data Submission ED/Hospital Arrival Dates through Contact Name Phone Title Fax Email Note Trauma...
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