<p> Actor Exercise Assessment Form</p><p>EXERCISE “VICTIM” Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated.</p><p>Field Assessment and Treatment: TAG 1. Initial Contact and Triage a. How long did it take response personnel to contact you?______Date of Exercise: [MM/DD/YYYY] Casualty #: ______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. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______VISIBLE SYMPTOMS: e. If you received a multicolored 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 assessment of your condition?</p><p>Child on ground with seizure ______activity ______Swollen eyes, tearing ______2. Treatment: Pallor and diaphoresis 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?</p><p>______</p><p>______</p><p>PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 6 and shallow ______Audible wheezing ______Pulse: 50 ______Hospital (if applicable) BP: 82/76 1. Which hospital did you go to? ______2. Once at the hospital, how long was it until someone examined you?  Less than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes  I was never examined at the hospital</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? OTHER PATIENT INFORMATION: ______</p><p>______</p><p>Unresponsive ______Moaning DO NOT LOSE THIS CARD! Excessive salivation and DO NOT LET ANYONE TAKE THIS CARD FROM YOU! runny nose</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) EXERCISE “VICTIM” SYMPTOMATOLOGY TAG</p><p>Date of Exercise: [MM/DD/YYYY] Casualty #: ______</p><p>VISIBLE SYMPTOMS:</p><p>Child on ground, moving all extremities Complains of difficulty breathing and blurred vision</p><p>PHYSICAL FINDINGS: </p><p>Resp: 32 and shallow Audible drooling and wheezing Pulse: 132 BP: 150/90</p><p>OTHER PATIENT INFORMATION: </p><p>Responsive Able to follow commands Talking but salivating</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the checkout station at the exercise site. EXERCISE “VICTIM” Please be accurate with your answers. Your cooperation is important and is appreciated. SYMPTOMATOLOGY Field Assessment and Treatment: 1. Initial Contact and 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? ______Date of Exercise: [MM/DD/YYYY] Casualty #: ______c. Were you examined on the scene more than once?  Yes  No d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______e. If you received a multicolored triage tag, what was the BOTTOM color when it was first given to you?  Green  Yellow  Red VISIBLE SYMPTOMS:  Black  Never received a tag f. What actions did response personnel take as a result of their assessment of your condition? ______Child on ground, moving ______Marked respiratory distress ______</p><p>2. Treatment: with obvious abdominal a. If conscious, did someone explain your treatment?  Yes  No b. If conscious, were you given clear instructions?  Yes  No discomfort c. What treatment was given? Tearing ______</p><p>______PHYSICAL FINDINGS: 3. Did you observe any outstanding actions among the response personnel you observed? ______Resp: 25 and erratic ______</p><p>______audible upper airway noise</p><p>Hospital (if applicable) and wheezing 1. Which hospital did you go to? ______2. Once at the hospital, how long was it until someone examined you? Pulse: 64  Less than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes  I was never examined at the hospital BP: 80/62</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______OTHER PATIENT INFORMATION: ______</p><p>DO NOT LOSE THIS CARD! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Responsive, anxious Able to follow commands Cannot walk with constricted pupils A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is appreciated.</p><p>Field Assessment and Treatment: 1. Initial Contact and 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 d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______e. If you received a multicolored 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 assessment of your condition?</p><p>______</p><p>______</p><p>______</p><p>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?</p><p>______</p><p>______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel you observed?</p><p>______</p><p>______</p><p>______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______2. Once at the hospital, how long was it until someone examined you?  Less than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes  I was never examined at the hospital</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>______</p><p>DO NOT LOSE THIS CARD! DO NOT LET ANYONE TAKE THIS CARD FROM YOU!</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated. Field Assessment and Treatment: 1. Initial Contact and Triage TAG a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin Date of Exercise: [MM/DD/YYYY] Casualty #: ______decontaminating you? ______c. Were you examined on the scene more than once?  Yes  No d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______e. If you received a multicolored triage tag, what was the BOTTOM VISIBLE SYMPTOMS: 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? Complaints of severe respiratory ______distress ______Raspy voice ______2. Treatment: Whites of eyes are reddened and a. If conscious, did someone explain your treatment?  Yes  No b. If conscious, were you given clear instructions?  Yes  No watering c. What treatment was given?</p><p>Extremely pale and sweating ______</p><p>______</p><p>______</p><p>3. Did you observe any outstanding actions among the response PHYSICAL FINDINGS: personnel you observed? ______</p><p>______Resp: 32, shallow ______Hospital (if applicable) Pulse: 80 1. Which hospital did you go to? ______BP: 82/62 2. Once at the hospital, how long was it until someone examined you?  Less than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes  I was never examined at the hospital</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>OTHER PATIENT INFORMATION: ______</p><p>______Aware; knows name and DO NOT LOSE THIS CARD! location only DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Unable to walk</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>EXERCISE “VICTIM” Please complete the following questions at the conclusion of the exercise. This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated.</p><p>Field Assessment and Treatment: TAG 1. Initial Contact and Triage a. How long did it take response personnel to contact you? ______Date of Exercise: [MM/DD/YYYY] Casualty #: ______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. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______VISIBLE SYMPTOMS: e. If you received a multicolored 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 assessment of your condition?</p><p>Child with active seizure ______Skin diaphoretic with loss of ______bowel and bladder control ______2. Treatment: Tearing and marked salivation 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?</p><p>______PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response Resp: 24 and shallow personnel you observed? Audible wheezing ______Pulse: 54 ______BP: 72/54 ______Hospital (if applicable) 1. Which hospital did you go to? ______2. Once at the hospital, how long was it 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?</p><p>______Unresponsive ______Unable to follow commands ______Moaning only DO NOT LOSE THIS CARD! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Unable to walk</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated. Field Assessment and Treatment: 1. Initial Contact and Triage TAG a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin Date of Exercise: [MM/DD/YYYY] Casualty #: ______decontaminating you? ______c. Were you examined on the scene more than once?  Yes  No d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______e. If you received a multicolored triage tag, what was the BOTTOM VISIBLE SYMPTOMS: 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? Child with marked tearing ______with complaint of blurred ______</p><p> vision 2. Treatment: a. If conscious, did someone explain your treatment?  Yes  No Wheezing with associated b. If conscious, were you given clear instructions?  Yes  No abdominal cramping c. What treatment was given? ______</p><p>______PHYSICAL FINDINGS: ______3. Did you observe any outstanding actions among the response personnel you observed? Resp: 28; audible wheezing ______Pulse: 62 ______</p><p>BP: 90/60 Hospital (if applicable) 1. Which hospital did you go to? ______2. Once at the hospital, how long was it 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?</p><p>______Responsive ______Follows commands ______Oriented DO NOT LOSE THIS CARD! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Able to walk but weak</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated. Field Assessment and Treatment: 1. Initial Contact and Triage TAG a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin Date of Exercise: [MM/DD/YYYY] Casualty #: ______decontaminating you? ______c. Were you examined on the scene more than once?  Yes  No d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______e. If you received a multicolored triage tag, what was the BOTTOM VISIBLE SYMPTOMS: 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? Child on ground, not moving ______Runny nose and ______</p><p> hypersalivation 2. Treatment: a. If conscious, did someone explain your treatment?  Yes  No Swollen eyes with tearing b. If conscious, were you given clear instructions?  Yes  No Pale and diaphoretic c. What treatment was given? ______</p><p>______</p><p>______</p><p>3. Did you observe any outstanding actions among the response PHYSICAL FINDINGS: personnel you observed?</p><p>______</p><p>______</p><p>Resp: 6 and shallow; no ______</p><p> audible breath sounds Hospital (if applicable) 1. Which hospital did you go to? Pulse: 32 ______2. Once at the hospital, how long was it until someone examined you? BP: 66/40  Less than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes  I was never examined at the hospital</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>OTHER PATIENT INFORMATION: ______</p><p>______</p><p>Unresponsive DO NOT LOSE THIS CARD! DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Unable to follow commands Moaning only Unable to walk A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated. Field Assessment and Treatment: 1. Initial Contact and Triage TAG a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin Date of Exercise: [MM/DD/YYYY] Casualty #: ______decontaminating you? ______c. Were you examined on the scene more than once?  Yes  No d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______e. If you received a multicolored triage tag, what was the BOTTOM VISIBLE SYMPTOMS: 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? Child with eyes tearing ______Coughing with abdominal ______</p><p> pain and drooling 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?</p><p>PHYSICAL FINDINGS: ______</p><p>______</p><p>______</p><p>Resp: 32 and shallow 3. Did you observe any outstanding actions among the response Audible wheezing personnel you observed? ______</p><p>Pulse: 64 ______</p><p>BP: 84/78 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______2. Once at the hospital, how long was it until someone examined you?  Less than 5 minutes  5 minutes  10 minutes  15 minutes OTHER PATIENT INFORMATION:  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? Responsive ______</p><p>Able to follow commands ______Able to speak DO NOT LOSE THIS CARD! Able to walk DO NOT LET ANYONE TAKE THIS CARD FROM YOU!</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) Actor Exercise Assessment Form</p><p>Please complete the following questions at the conclusion of the exercise. EXERCISE “VICTIM” This card is to be turned in at the checkout station at the exercise site. Please be accurate with your answers. Your cooperation is important and is SYMPTOMATOLOGY appreciated. Field Assessment and Treatment: 1. Initial Contact and Triage TAG a. How long did it take response personnel to contact you? ______b. How long did it take response personnel to begin Date of Exercise: [MM/DD/YYYY] Casualty #: ______decontaminating you? ______c. Were you examined on the scene more than once?  Yes  No d. Whom did you talk to, or whom were you assessed by (list all)?  Fire  EMS  Police  Other ______VISIBLE SYMPTOMS: e. If you received a multicolored 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 assessment of your condition?</p><p>Anxious child ______</p><p>Swollen eyes with tearing ______Blurred vision ______Cough 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?</p><p>PHYSICAL FINDINGS: ______</p><p>______</p><p>______</p><p>Resp: 20 and shallow, audible 3. Did you observe any outstanding actions among the response wheezing personnel you observed? Pulse: 128 ______BP: 134/88 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______2. Once at the hospital, how long was it until someone examined you?  Less than 5 minutes  5 minutes  10 minutes  15 minutes OTHER PATIENT INFORMATION:  Over 15 minutes  I was never examined at the hospital</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Responsive ______Able to follow commands ______Speaking in short sentences ______Able to walk but weak DO NOT LOSE THIS CARD! DO NOT LET ANYONE TAKE THIS CARD FROM YOU!</p><p>A ride has been scheduled to return you to the exercise site. If you are not picked up, please call: [Insert number].</p><p>Thank you for your participation!</p><p>ST (L) ST (L)</p>