<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 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? ______</p><p>______Resp: 10 ______3. Did you observe any outstanding actions among the response personnel Pulse: 120 you observed? BP: 80/40 ______</p><p>______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation Moans to painful in the exercise? What improvements would you suggest? stimulation ______</p><p>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.</p><p>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 ______</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? PHYSICAL FINDINGS: ______</p><p>______</p><p>______</p><p>Resp: 10 3. Did you observe any outstanding actions among the response personnel Pulse: 80 you observed? ______</p><p>BP: 80/40 ______</p><p>______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation Alert and oriented in the exercise? What improvements would you suggest? ______</p><p>Able to follow ______commands ______</p><p>No respiratory DO NOT LOSE THIS CARD!! distress DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Thank you for your participation</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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?</p><p>Cannot walk ______</p><p>______</p><p>PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed?</p><p>______</p><p>Resp: 10 ______Pulse: 82 ______Hospital (if applicable) BP:100/60 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation OTHER PATIENT INFORMATION: in the exercise? What improvements would you suggest?</p><p>______</p><p>______Confused ______</p><p>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</p><p> distress Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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</p><p> 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?</p><p>______</p><p>______PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 12, ______</p><p> irregular ______</p><p>Pulse: 50 Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>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</p><p>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</p><p> 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?</p><p>______</p><p>______</p><p>PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed?</p><p>______</p><p>Resp: 24 ______Pulse: 122 ______Hospital (if applicable) BP:105/48 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______Alert and oriented ______</p><p>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</p><p>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</p><p>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 ______</p><p> 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?</p><p>______PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel Resp: 18 you observed? ______</p><p>Pulse: 90 ______</p><p>BP: 130/90 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>Alert but confused ______</p><p>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</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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 ______</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>PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel you observed?</p><p>Resp: 10 ______Pulse: 38 ______BP:80/44 ______Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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?</p><p>______Unconscious ______Unable to follow ______</p><p> commands DO NOT LOSE THIS CARD!! No respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! distress Thank you for your participation</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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 ______</p><p>Responsive ______</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>______PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel Resp: 18 you observed? Pulse: 108 ______</p><p>BP: 130/82 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Alert and oriented ______</p><p>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</p><p>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</p><p>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 ______</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>______PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel Resp: 32 you observed? ______</p><p>Pulse: 120 ______</p><p>BP:190/108 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>Alert and oriented ______</p><p>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</p><p>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</p><p>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 ______</p><p>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?</p><p>______</p><p>PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel you observed?</p><p>Resp: 20 ______Pulse: 120 ______BP: 96/70 ______Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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?</p><p>______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</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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</p><p> 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?</p><p>______</p><p>______PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 18 ______</p><p>Pulse: 80 ______</p><p>BP: 110/70 Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>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</p><p>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</p><p> 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?</p><p>32 weeks ______</p><p>______PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 48 ______</p><p>Pulse: 110 ______</p><p>BP: 90/72 Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>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</p><p>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</p><p> 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?</p><p> bleeding ______</p><p>______PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 22 ______</p><p>Pulse: 112 ______</p><p>BP: 90/74 Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>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</p><p>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</p><p> 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? ______</p><p>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?</p><p>PHYSICAL FINDINGS: ______</p><p>______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel Resp: 24 you observed? Pulse: 84 ______BP: 120/80 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>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</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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</p><p> 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?</p><p> ears ______</p><p>______PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 32 ______</p><p>Pulse: 142 ______</p><p>BP: 100/40 Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>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</p><p>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</p><p> 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?</p><p>______</p><p>______PHYSICAL FINDINGS: ______</p><p>3. Did you observe any outstanding actions among the response personnel you observed? Resp: 10, ______</p><p> irregular ______</p><p>Pulse: 40 Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>OTHER PATIENT INFORMATION: Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest?</p><p>______</p><p>______</p><p>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</p><p>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</p><p> 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?</p><p>______</p><p>PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel you observed?</p><p>Resp: 28 ______Pulse: 110 ______BP:200/110 ______Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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?</p><p>______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</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc.</p><p>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 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 ______</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>______PHYSICAL FINDINGS: ______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel Resp: 36 you observed? ______</p><p>Pulse: 110 ______</p><p>BP: 190/102 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation in the exercise? What improvements would you suggest? Alert and oriented, ______</p><p> 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</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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</p><p> 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? ______</p><p> 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?</p><p>PHYSICAL FINDINGS: ______</p><p>______</p><p>______</p><p>3. Did you observe any outstanding actions among the response personnel Resp: 36 you observed? Pulse: 146 ______BP: 80/40 ______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>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</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. 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 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 ______</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? PHYSICAL FINDINGS: ______</p><p>______</p><p>______</p><p>Resp: 28 3. Did you observe any outstanding actions among the response personnel Pulse: 110 you observed? ______</p><p>BP:200/110 ______</p><p>______</p><p>Hospital (if applicable) 1. Which hospital did you go to? ______</p><p>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</p><p>Exercise Design: Did you observe any problems during your participation Alert and oriented, in the exercise? What improvements would you suggest? ______</p><p> anxious ______Able to follow ______</p><p> commands DO NOT LOSE THIS CARD!! Marked respiratory DO NOT LET ANYONE TAKE THIS CARD FROM YOU! Thank you for your participation</p><p>Apply another label here for additional exercise information -- Meal, Transportation, Check-Out, etc. </p>