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Importance Unnecessary interfacility transfer of minimally injured patients to a level I trauma center (secondary overtriage) can cause inefficient use of resources and personnel within a regional trauma system. Objective To describe the burden of secondary overtriage in a rural trauma system with a single level I trauma center. Design Retrospective analysis of institutional trauma registry data. Setting Dartmouth Hitchcock Medical Center, a rural level I trauma center. Patients A total of 7793 injured patients evaluated by the trauma service at Dartmouth Hitchcock Medical Center from January 1, 2007, to December 31, 2011. Exposure Evaluation by the trauma service. Main Outcomes and Measures Patients transferred from another hospital to Dartmouth Hitchcock Medical Center who did not require an operation, had an Injury Severity Score lower than 15, and were discharged alive within 48 hours of admission. Results Of the 7793 evaluated patients, 4796 (62%) were transferred from other facilities. When compared with scene calls (n = 2997), transferred patients had a similar median Injury Severity Score of 9, but 24% of transferred adult patients and 49% of transferred pediatric patients met our definition of secondary overtriage. The overtriaged patients were most likely to have injuries of the head and neck (56%), followed by skin and soft-tissue injuries (41%). Seventy-two unique institutions transferred trauma patients to Dartmouth Hitchcock Medical Center, but 36% of the overtriaged patients were from 5 institutions. Conclusions and Relevance The incidence of secondary overtriage in our rural trauma center is 26%, with head and neck injuries being the most common reason for transfer. Costs for transportation and additional evaluation for such a significant percentage of patients has important resource utilization implications. Effective regionalization of rural trauma care should include methods to limit secondary overtriage.