Texas EMS Wristband Request Form

Texas EMS Wristband Request Form
General Information:

The Texas Wristband Project will electronically link pre-hospital to hospital patient records throughout the continuum of care and resolve any extenuating circumstances with patient accountability during disaster-related incidents, mass casualties, and evacuations. All patients presenting with a Texas Wristband should have the number logged on their EMS and trauma patient records.

SETRAC is providing a one time allotment of the Texas EMS Wristband to our EMS and hosptial partners of TSA-Q, H, & R.

These wristbands will be appropriately distrubuted to DSHS-Licensed EMS agencies, and hosptials to facilitate EMS transports, inter-facility transfers, and/or other SETRAC approved situations or events in which wristbands may be needed or required (i.e. MCI).

Eligibility:

To request wristbands see the Request Reminders on the next page prior to completeing the form to determine eligibility.

Request Reminders

To request wristbands please be aware of the following requirments.
- Must have one of the following memberships:
  - SETRAC General Membership in good standing*
  - HPP Participating Agreement
  - EMTF Memorandum of Agreement
*SETRAC Membership in good standing includes:
- Membership dues are current
- Meet participation requirments:
  - Attended 6 SETRAC meetings within RAC fiscal year (Sept. 1 – Aug.31) (For EMS: 3 must be EMS SQI meetings, and 3 can be of the following categories: additional EMS SQI meetings, SETRAC Board meetings, RHPC Corridor meetings, Clinical meetings (Stroke, Cardiac, or Trauma).

Request Form
Agency/Organization *
Address of Agency/Organization*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Requestor*

First NameLast Name
Job title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Does your agency utilize Pulsara?*

YESNOOther
Does your agency plan to utilize the EMS Wristbands for day-to-day use when transporting patients to the hospital?*

YESNOOther
Does your agency plan to utilize the EMS Wristbands for use during a disaster event?*

YESNOOther
Amount Requested**
*Requesting EMS agencies - Please request a 1 year supply based on the annual number of patient transports.
By signing below, I, as a representative of the above-listed organization, agree to follow SETRAC regional guidelines for the appropriate use of the Texas EMS Wristband during patient care.*

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Resource Requested/Filled
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