Texas EMS Wristband Request Form

General Information
The Texas Wristband Project is a statewide initiative that 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 in ther respected care records (ePCR and EMR).

These wristbands will be appropriately distributed to DSHS-Licensed EMS agencies, and hospitals 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, evacuation).

For more information, please contact a SETRAC team member.

Hospital Request Form

Please complete a form for each hospital - not system wide.
Hospital Name*
Address of Hospital*

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 hospital utilize Pulsara?*

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

YESNO
Amount Requested**
*Hospitals: Level 1 Trauma Centers: 3 Cases. Level 2 Trauma Centers: 2 Cases. All others: 1 Case. (5,000/case)

EMS Request Form
EMS Agency Name*
Address of EMS Agency*

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/organization plan to utilize the EMS Wristbands for use during a disaster event?*

YESNOOther
Amount Requested**
EMS: Request a 1 year supply based on the annual number of patient transports.

Signature Page
By signing below, I, as a representative of the organization listed on this form, acknowledge receipt of an allotment of wristbands from SETRAC and agree to adhere to regional guidelines for the proper use of the Texas EMS Wristband.*

Clear
Amount Given to Requestor
Should be Empty:

Eligibility/Requirements: