Trauma Accreditation Resources
Educational resources compiled by the Pennsylvania Trauma Systems Foundation to assist Pennsylvania hospitals and medical centers’ pursuits of trauma accreditation are listed below.
Information about how to apply for a site survey, updated copies of the PTSF Standards of Accreditation, and ACS Accreditation Guidelines are listed as well.
If the information that you are looking for is not found here, please contact a member of the PTSF staff—they are always happy to help.
**NEW PENNSYLVANIA TRAUMA PROGRAM NURSE LEADERS**
New Trauma Program Nurse Leader Orientation – August 19, 2025 – 10:00 a.m. to 3:00 p.m.
Educational Videos
Site Survey Information
Survey Guidebook
This guidebook was developed to assist trauma program staff with their preparation for the accreditation survey. This document is written for all trauma levels, including both pursuing and accredited trauma centers.
This guidebook was developed to assist trauma program staff with their preparation for the accreditation survey. This document is written for all trauma levels, including both pursuing and accredited trauma centers.
763.12K
Significant Issue Action Plan Template
Required template for submitting an action plan for each Significant Issue identified during the accreditation process. Submit to PTSF Accreditation Staff by the due date listed on the accreditation report cover letter.
Required template for submitting an action plan for each Significant Issue identified during the accreditation process. Submit to PTSF Accreditation Staff by the due date listed on the accreditation report cover letter.
64.23K
Accreditation Policy (AC-106)
Transition Period for the Implementation of New or Revised Standards of Accreditation
Transition Period for the Implementation of New or Revised Standards of Accreditation
137.39K
189.03K
Site Survey Toolkit
Trauma Program Medical Director Continuing Education Template
List the Trauma Program Medical Director's continuing education for the survey cycle.
List the Trauma Program Medical Director's continuing education for the survey cycle.
0.00P
Trauma Program Manager Continuing Education Template
List the Trauma Program Manager’s continuing education for the survey cycle.
List the Trauma Program Manager’s continuing education for the survey cycle.
36.15K
36.26K
36.79K
Emergency Medicine Template
List the Emergency Medicine Physicians who provide coverage for the survey cycle.
List the Emergency Medicine Physicians who provide coverage for the survey cycle.
37.11K
Alternate Pathway Request
Approval Process for use of Non-Board Certified Physicians: Alternate Pathway
Approval Process for use of Non-Board Certified Physicians: Alternate Pathway
270.91K
Letter of Intent and Letter of Request Templates
Letter of Intent (LOI) to Pursue Trauma Center Accreditation and Letter of Request (LOR) for Site Survey
Letter of Intent (LOI) to Pursue Trauma Center Accreditation and Letter of Request (LOR) for Site Survey
80.70K
Survey Guidebook
This guidebook was developed to assist trauma program staff with their preparation for the accreditation survey. This document is written for all trauma levels, including both pursuing and accredited trauma centers.
This guidebook was developed to assist trauma program staff with their preparation for the accreditation survey. This document is written for all trauma levels, including both pursuing and accredited trauma centers.
763.12K
Committee Attendance Log Template
Tracking Template for Multidisciplinary Peer Review PI Meeting Attendance — Required for AFS
Tracking Template for Multidisciplinary Peer Review PI Meeting Attendance — Required for AFS
92.33K
Education and Credentialing Site Survey Report Template
Education and Credentialing Site Survey Report Template (Word Format)
Education and Credentialing Site Survey Report Template (Word Format)
39.06K
Education and Credentialing Site Survey Report Template
*NEW* Education and Credentialing Site Survey Report Template (Excel Format). Automatic calculations and non-compliant areas turn red to alert non-compliance and the need for a comment to explain.
*NEW* Education and Credentialing Site Survey Report Template (Excel Format). Automatic calculations and non-compliant areas turn red to alert non-compliance and the need for a comment to explain.
24.51K
Alternate Pathway Provider Medical Record Form
Institutions with Alternate Pathway providers: Submit one week prior to survey
Institutions with Alternate Pathway providers: Submit one week prior to survey
77.50K
Standards of Accreditation
Resources for Optimal Care of the Injured Patient
American College of Surgeons Committee on Trauma Resources for Optimal Care of the Injured Patient, 7th Edition "The Gray Book"
American College of Surgeons Committee on Trauma Resources for Optimal Care of the Injured Patient, 7th Edition "The Gray Book"