Exercise Victim s1
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Actor Exercise Assessment Form
EXERCISE “VICTIM” Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and SYMPTOMATOLOGY is appreciated. Field Assessment and Treatment: TAG 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes VISIBLE SYMPTOMS: No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the Major crush injuries BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag to lower abdomen; f. What actions did response personnel take as a result of their assessment of your condition? unable to walk ______2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No PHYSICAL FINDINGS: c. What treatment was given? ______
______Resp: 10 ______3. Did you observe any outstanding actions among the response personnel Pulse: 120 you observed? BP: 80/40 ______
______
Hospital (if applicable) 1. Which hospital did you go to? ______OTHER PATIENT INFORMATION: 2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation Moans to painful in the exercise? What improvements would you suggest? stimulation ______
Able to follow ______commands DO NOT LOSE THIS CARD!! No respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Thank you for your participation Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc.
Actor Exercise Assessment Form EXERCISE “VICTIM” Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and SYMPTOMATOLOGY is appreciated. Field Assessment and Treatment: TAG 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No VISIBLE SYMPTOMS: d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Severe vomiting Yellow Red Black Never received a Tag Crush injury to right f. What actions did response personnel take as a result of their assessment of your condition? foot Unable to walk ______
______2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given? PHYSICAL FINDINGS: ______
______
______
Resp: 10 3. Did you observe any outstanding actions among the response personnel Pulse: 80 you observed? ______
BP: 80/40 ______
______
Hospital (if applicable) 1. Which hospital did you go to? ______
OTHER PATIENT INFORMATION: 2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation Alert and oriented in the exercise? What improvements would you suggest? ______
Able to follow ______commands ______
No respiratory DO NOT LOSE THIS CARD!! distress DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. Field Assessment and Treatment: EXERCISE “VICTIM” 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______SYMPTOMATOLOGY b. How long did it take response personnel to begin decontaminating you? ______TAG c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green VISIBLE SYMPTOMS: Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Contusion to ______forehead ______Fluctuating level of 2. Treatment: a. If conscious, did someone explain your treatment? Yes No consciousness b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
Cannot walk ______
______
PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed?
______
Resp: 10 ______Pulse: 82 ______Hospital (if applicable) BP:100/60 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation OTHER PATIENT INFORMATION: in the exercise? What improvements would you suggest?
______
______Confused ______
Unable to follow DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory Thank you for your participation
distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Severe head injury ______Contusions to face ______and forehead 2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
______PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed? Resp: 12, ______
irregular ______
Pulse: 50 Hospital (if applicable) 1. Which hospital did you go to? ______
BP: 170/100 2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______
Unconscious ______Unable to follow DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory Thank you for your participation distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Partial ______amputation of ______2. Treatment: right forearm a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
______
PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed?
______
Resp: 24 ______Pulse: 122 ______Hospital (if applicable) BP:105/48 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______Alert and oriented ______
Able to follow DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory Thank you for your participation distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and EXERCISE “VICTIM” is appreciated. Field Assessment and Treatment: 1. Initial Contact & Triage
SYMPTOMATOLOGY a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______VISIBLE SYMPTOMS: e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their Minor head injury assessment of your condition? Bleeding from left ______
ear Unable to ______stand without 2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No assistance c. What treatment was given?
______PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel Resp: 18 you observed? ______
Pulse: 90 ______
BP: 130/90 ______
Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 OTHER PATIENT INFORMATION: minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
Alert but confused ______
Able to follow some ______commands DO NOT LOSE THIS CARD!! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory distress Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and EXERCISE “VICTIM” is appreciated. Field Assessment and Treatment: SYMPTOMATOLOGY 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______TAG b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______VISIBLE SYMPTOMS: e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their Head injury assessment of your condition? Active seizure ______
______2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel you observed?
Resp: 10 ______Pulse: 38 ______BP:80/44 ______Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 OTHER PATIENT INFORMATION: minutes I was never examined at the hospital Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______Unconscious ______Unable to follow ______
commands DO NOT LOSE THIS CARD!! No respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! distress Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and EXERCISE “VICTIM” is appreciated. Field Assessment and Treatment: SYMPTOMATOLOGY 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______TAG b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______VISIBLE SYMPTOMS: e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their Crush injuries to assessment of your condition? right arm ______
Responsive ______
2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel Resp: 18 you observed? Pulse: 108 ______
BP: 130/82 ______
Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less OTHER PATIENT INFORMATION: than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Alert and oriented ______
Able to follow ______DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory distress Thank you for your participation Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and EXERCISE “VICTIM” is appreciated. Field Assessment and Treatment: 1. Initial Contact & Triage
SYMPTOMATOLOGY a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______VISIBLE SYMPTOMS: e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their Open chest assessment of your condition? wound ______
______
2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel Resp: 32 you observed? ______
Pulse: 120 ______
BP:190/108 ______
Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 OTHER PATIENT INFORMATION: minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
Alert and oriented ______
Able to follow ______DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Moderate respiratory distress Thank you for your participation Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and EXERCISE “VICTIM” is appreciated. Field Assessment and Treatment: 1. Initial Contact & Triage
SYMPTOMATOLOGY a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______VISIBLE SYMPTOMS: e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their Deformed right assessment of your condition? arm Vomiting ______
Unable to find ______2. Treatment: lost parents a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel you observed?
Resp: 20 ______Pulse: 120 ______BP: 96/70 ______Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______Alert and oriented ______Able to follow simple ______commands DO NOT LOSE THIS CARD!! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory distress Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Contusion to head ______Bleeding from left ______ear Abrasions to 2. Treatment: a. If conscious, did someone explain your treatment? Yes No both knees b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
______PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed? Resp: 18 ______
Pulse: 80 ______
BP: 110/70 Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______
Alert but confused ______Able to follow visual DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory Thank you for your participation distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Complaining of ______weakness; ______Vomiting; 2. Treatment: a. If conscious, did someone explain your treatment? Yes No Hyperventilating; b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
32 weeks ______
______PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed? Resp: 48 ______
Pulse: 110 ______
BP: 90/72 Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______
Alert and oriented, ______anxious DO NOT LOSE THIS CARD!! Able to follow DO NOT LET ANYONE TAKE THIS CARD FROM YOU! commands Thank you for your participation No respiratory Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Nauseous ______Multiple cuts on ______left arm and left 2. Treatment: a. If conscious, did someone explain your treatment? Yes No leg with active b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
bleeding ______
______PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed? Resp: 22 ______
Pulse: 112 ______
BP: 90/74 Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______
Alert and oriented, ______anxious DO NOT LOSE THIS CARD!! Able to follow DO NOT LET ANYONE TAKE THIS CARD FROM YOU! commands Thank you for your participation No respiratory Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. SYMPTOMATOLOGY Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? TAG ______b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list VISIBLE SYMPTOMS: all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Complains of Black Never received a Tag f. What actions did response personnel take as a result of their headaches assessment of your condition? ______
Contusion to left ______forehead ______2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
PHYSICAL FINDINGS: ______
______
______
3. Did you observe any outstanding actions among the response personnel Resp: 24 you observed? Pulse: 84 ______BP: 120/80 ______
Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less OTHER PATIENT INFORMATION: than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Alert and oriented ______Able to follow ______commands ______DO NOT LOSE THIS CARD!! No respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! distress Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Crushed chest ______Abrasion to left ______forehead 2. Treatment: a. If conscious, did someone explain your treatment? Yes No Bleeding from both b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
ears ______
______PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed? Resp: 32 ______
Pulse: 142 ______
BP: 100/40 Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______
Alert but confused ______Able to follow simple DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Marked respiratory Thank you for your participation distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Serious head ______injury with ______deformity of skull 2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
______PHYSICAL FINDINGS: ______
3. Did you observe any outstanding actions among the response personnel you observed? Resp: 10, ______
irregular ______
Pulse: 40 Hospital (if applicable) 1. Which hospital did you go to? ______
BP: 180/110 2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______
______
Unconscious ______Does not react to DO NOT LOSE THIS CARD!! pain DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory Thank you for your participation distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. EXERCISE “VICTIM” Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? SYMPTOMATOLOGY ______b. How long did it take response personnel to begin TAG decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the VISIBLE SYMPTOMS: BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag f. What actions did response personnel take as a result of their assessment of your condition? Multiple ______abrasions and ______laceration to left ______2. Treatment: forearm a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______
PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel you observed?
Resp: 28 ______Pulse: 110 ______BP:200/110 ______Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?
______Alert and oriented, ______anxious ______No respiratory DO NOT LOSE THIS CARD!! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! distress Thank you for your participation Ambulatory
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc.
Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. EXERCISE “VICTIM” Please be accurate with your answers. Your cooperation is important and is appreciated. Field Assessment and Treatment: SYMPTOMATOLOGY 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______TAG b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list all)? VISIBLE SYMPTOMS: Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Black Never received a Tag Hyperventilating; f. What actions did response personnel take as a result of their assessment of your condition? Frantic ______
______2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
______PHYSICAL FINDINGS: ______
______
3. Did you observe any outstanding actions among the response personnel Resp: 36 you observed? ______
Pulse: 110 ______
BP: 190/102 ______
Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 OTHER PATIENT INFORMATION: minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Alert and oriented, ______
extremely anxious ______Able to follow DO NOT LOSE THIS CARD!! commands DO NOT LET ANYONE TAKE THIS CARD FROM YOU! No respiratory Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated. SYMPTOMATOLOGY Field Assessment and Treatment: 1. Initial Contact & Triage
a. How long did it take response personnel to contact you? TAG ______b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No d. Who did you talk to, or whom were you assessed by (list VISIBLE SYMPTOMS: all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Yellow Red Obvious Black Never received a Tag f. What actions did response personnel take as a result of their respiratory assessment of your condition? ______
distress ______Bleeding from ______2. Treatment: a. If conscious, did someone explain your treatment? Yes No both ears b. If conscious, were you given clear instructions? Yes No c. What treatment was given?
PHYSICAL FINDINGS: ______
______
______
3. Did you observe any outstanding actions among the response personnel Resp: 36 you observed? Pulse: 146 ______BP: 80/40 ______
Hospital (if applicable) 1. Which hospital did you go to? ______
2. Once at the hospital, how long until someone examined you? Less OTHER PATIENT INFORMATION: than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Alert and confused ______Able to follow ______commands ______DO NOT LOSE THIS CARD!! Severe respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! distress Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. Actor Exercise Assessment Form
EXERCISE “VICTIM” Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the Check-Out Station, at the exercise site. Please be accurate with your answers. Your cooperation is important and SYMPTOMATOLOGY is appreciated. Field Assessment and Treatment: TAG 1. Initial Contact & Triage a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin decontaminating you? ______c. Were you examined on the scene more than once? Yes No VISIBLE SYMPTOMS: d. Who did you talk to, or whom were you assessed by (list all)? Fire EMS Police Other ______e. If you received a multi-colored Triage Tag, what was the BOTTOM color when it was first given to you? Green Foreign object Yellow Red Black Never received a Tag stuck in throat f. What actions did response personnel take as a result of their assessment of your condition? Active bleeding ______
______2. Treatment: a. If conscious, did someone explain your treatment? Yes No b. If conscious, were you given clear instructions? Yes No c. What treatment was given? PHYSICAL FINDINGS: ______
______
______
Resp: 28 3. Did you observe any outstanding actions among the response personnel Pulse: 110 you observed? ______
BP:200/110 ______
______
Hospital (if applicable) 1. Which hospital did you go to? ______
OTHER PATIENT INFORMATION: 2. Once at the hospital, how long until someone examined you? Less than 5 minutes 5 minutes 10 minutes 15 minutes Over 15 minutes I was never examined at the hospital
Exercise Design: Did you observe any problems during your participation Alert and oriented, in the exercise? What improvements would you suggest? ______
anxious ______Able to follow ______
commands DO NOT LOSE THIS CARD!! Marked respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Thank you for your participation
Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc.