NC-COT Membership Application FormNC-COT Membership Application Form Personal InformationName * Name Name Name Title Institution Email * Specialty * Level of Training * Attending Physician Fellow Resident OtherOther Membership Category * Active (must be FACS)Associate (non-FACS physician)Advisory (non-physician)Physician in-training General COT QuestionsHave you completed, or are you currently enrolled in any of the following fellowships Trauma Burn Surgical Critical Care Acute Care Surgery None of the above Other (please specify)Other (please specify)Are you a Member of the American College of Surgeons? * Yes NoAre you a Member of the NC Chapter of the American College of Surgeons? * Yes NoAre you currently active in the field of trauma? * Yes No Please describe * What percentage of your current professional activities involves the care of the injured patient? * 0-50%50%-75%> 75% Have you been actively involved with the NC-COT? * Yes No Please describe * Are you currently working at Level I, Level II or Level III Trauma Center? * Level ILevel IILevel IIINo COT Activity Questions **Hidden**What special skills and/or areas of accomplishment do you bring to the work of the COT in any of the following areas? Trauma Quality Trauma Education ATLS PI/Outcomes Trauma Systems Trauma Research Trauma Center Evaluation Guideline Development Emergency/pre-hospital care Pediatric Trauma Burns Injury Prevention Rural Trauma Advocacy Other (specify) COT Activity QuestionsWhat special skills and/or areas of accomplishment do you bring to the work of the COT in any of the following areas? Trauma Quality Trauma Education ATLS PI/Outcomes Trauma Systems Trauma Research Trauma Center Evaluation Guideline Development Emergency/pre-hospital care Pediatric Trauma Burns Injury prevention Rural trauma Advocacy Other (specify)Other (specify)QuestionnaireWhat special skills and/or areas of accomplishment do you bring to the work of the COT in any of the following area?Have you taken the ATLS® Provider course? * Yes NoHave you taken the ATLS® Instructor course? * Yes No How often do you teach ATLS®? * Are you an ATLS® Course Director? * Yes No How often do you direct an ATLS® course? * Does your hospital participate in the ACS Trauma Quality Improvement Project (TQIP)? * Yes NoHave you used the COT prevention materials? * Yes NoAre you involved in Stop the Bleed Training? * Yes NoIs your hospital verified by ACS? * Yes NoHave you taken the COT Disaster Management and Preparedness course? * Yes NoAre you a member of the American Association for the Surgery of Trauma? * Yes NoAre you a member of any other trauma-related organizations? * Yes No Please specify * Are you willing to attend the quarterly NC-COT Meetings? * Yes No If you are human, leave this field blank. SubmitΔ
