Tourniquet Survey

This form is intended to assist NTRAC in surveillance of the Stop the Bleed tourniquet training.  Please fill out this form completely after each use of a tourniquet, including improvised tourniquets.  Do not place any protected health information on this form.  This information will be kept secure and used for process improvement and data collection only.  

Q1
Q2
Q3Procedure Performance
Q4Was Stop the Bleed training used
Q5Style of tourniquet used
 
Q6Was application successful

Patient Demographic

Q7
Q8Sex
Q9Class
Q10Body Type
Q11
Q12
Q13
 
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