NCTTRAC Member Contacts and Delegates Update Form

Thank you for updating your organization’s Contacts and Delegates. Keeping this information up to date allows NCTTRAC to better communicate with your organization.

If you have any questions or need any additional assistance, please contact NCTTRAC Admin at 817-608-0390 or ncttrac_admin@ncttrac.org

**Only Primary Voting Representatives should be completing this form.

Fields marked with an * are required.

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Person Completing Form

First Name *

Last Name *

Organization *

Title *

Email *

Phone *

Organization Type *

Update Required *

Does any of the information in the Related Organization>NCTTRAC Contacts and Delegates tab in Member Hub need to be updated?

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Administration Contacts

Senior Executive Officer

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Senior Executive Assistant

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Chief Medical Officer

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Chief Nursing Officer

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Chief Financial Officer

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Additional Chief or Executive

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

24/7 Emergency Contacts

24-7 Emergency Contact

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Administrator On-Call

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Patient Transfer Line

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Air Medical Committee
If other than Primary Voting Representative

Air Medical-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Air Medical-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Cardiac Committee
If other than Primary Voting Representative.

Cardiac-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Cardiac-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Cardiac-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Cardiac - Chest Pain Coordinator

First Name	Last Name	Title	Phone Number	Email	Chage Type	Effective Date

Emergency Medical Services Committee
If other than Primary Voting Representative.

EMS-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

EMS-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

EMS Liaison

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Emergency Department Operations Committee
If other than Primary Voting Representative.

ED OPS-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

ED OPS-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

ED Ops-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

ED Ops-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Finance Committee
If other than Primary Voting Representative.

Finance-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Finance-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Pediatric Committee
If other than Primary Voting Representative.

Pediatric-Delegated Voting Rep

First Name	Last Name	Titl	Phone	Email	Change Type	Effective Date

Pediatric-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal Committee
If other than Primary Voting Representative.

Perinatal-Maternal Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Maternal Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Maternal Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Maternal Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Neonatal-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Neonatal-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Neonatal-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Perinatal-Neonatal-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Regional Emergency Preparedness Committee
If other than Primary Voting Representative.

REPC-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

REPC-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

REPC-Emergency Preparedness Coordinator (EPC)

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

REPC-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

REPC-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Stroke Committee
If other than Primary Voting Representative.

Stroke-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Stroke-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Stroke-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Stroke-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Trauma Committee
If other than Primary Voting Representative.

Trauma-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Trauma-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Trauma-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Trauma-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Trauma-Injury Prevention Coordinator

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Acknowledgement

Comments

Acknowledgement *

By checking this box, I, as Primary Voting Representative, commit to delegated representative updates. I acknowledge my responsibilities to review my organization’s contacts and delegates in the NCTTRAC Contact Management Program (powered by GrowthZone) once my organization’s membership is approved by the NCTTRAC Board of Directors.

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EMS Administration Contacts

Chief or Executive

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Administrative Assistant

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Assistant Chief or Executive

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Budget Administrator

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

EMS Chief or Executive

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Additional Chief or Executive

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Emergency, Medical Director, and PSAP Contacts

24-7 Emergency Contact

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

24-7 Non-Emergency Contact

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

911 PSAP Administrator

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Air Medical Committee (EMS)
If other than Primary Voting Representative

Air Medical-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Air Medical-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Air Medical-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Air Medical-Program Medical Director

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Cardiac Committee (EMS)
If other than Primary Voting Representative.

Cardiac-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Cardiac-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Emergency Medical Services Committee (EMS)
If other than Primary Voting Representative.

EMS-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

EMS-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

EMS-Program Manager

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Emergency Department Operations Committee (EMS)
If other than Primary Voting Representative.

ED Ops-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

ED Ops-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Finance Committee (EMS)
If appointed to Committee core group position.

Finance-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Finance-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

EMS Medical Director Committee (EMS)
If appointed to Committee core group position.

Medical Director-Delegated Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Medical Director-Alternate Voting Rep

First Name	Last Name	Title	Phone	Email	Change Type	Effective Date

Pediatric Committee (EMS)
If other than Primary Voting Representative.