Labels - Severe Symptoms - VX
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 1
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Pain Right Leg
Right open femur fracture with external fixation to femur
PHYSICAL FINDINGS:
Resp: 16
Pulse: 82
BP: 119/59
OTHER PATIENT INFORMATION:
Aware; knows name and location
Unable to walk
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 2
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
C/O Shoulder and Hip Pain
Impaled objects to shoulder and hip
PHYSICAL FINDINGS:
Resp: 16
Pulse: 76
BP: 130/51
OTHER PATIENT INFORMATION:
Aware; knows name and location
Unable to walk
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 3
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Decreased LOC
Head laceration
PHYSICAL FINDINGS:
Resp: 8
Pulse: 45
BP: 75/45
OTHER PATIENT INFORMATION:
Difficulty with responsiveness
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-17 Scenario #: 4
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Resident is missing.
PHYSICAL FINDINGS:
--
OTHER PATIENT INFORMATION:
Dementia; knows name but not time or place
Tends to wander.
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 5
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Unresponsive
PHYSICAL FINDINGS:
Resp: 0
Pulse: Not palpable/audible
BP: None
OTHER PATIENT INFORMATION:
DNR
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 6
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Emotional Stress (PTSD?)
Tearful, anxious, unable to sit still
PHYSICAL FINDINGS:
Resp: 24
Pulse: 95
BP: 148/88
OTHER PATIENT INFORMATION:
Tearful, anxious, unable to sit still
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 7
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Short of breath at rest
Nasal flaring when breathing
PHYSICAL FINDINGS:
Resp: 32
Pulse: 116
BP: 146/88
OTHER PATIENT INFORMATION:
Anxious
Alert and responsive
Absent breath sounds on right
Struggling to breathe
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 8
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Leg pain, decreased LOC
Left leg nearly amputated below the knee
PHYSICAL FINDINGS:
Resp: 17
Pulse: 134
BP: 145/90
OTHER PATIENT INFORMATION:
Confused; in and out of consciousness
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 9
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Painful right arm
Open radius fracture
PHYSICAL FINDINGS:
Resp: 24
Pulse: 123
BP: 165/76
OTHER PATIENT INFORMATION:
Alert; responsive
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 10
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Right eye pain; diplopia
Extreme edema and discoloration
PHYSICAL FINDINGS:
Resp: 20
Pulse: 95
BP: 130/85
OTHER PATIENT INFORMATION:
Alert; responsive
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History: Falling debris struck eye
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? ________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 11
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Pain pelvic area
Urge/inability to urinate
Fractured Pelvis
PHYSICAL FINDINGS:
Resp: 18
Pulse: 72
BP: 104/62
OTHER PATIENT INFORMATION:
Alert, responsive
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: Scenario #: 12
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Headache
Transient LOC with mild confusion
Concussion
PHYSICAL FINDINGS:
Resp: 20
Pulse: 70
BP: 140/86
OTHER PATIENT INFORMATION:
Confused, asks same questions repeatedly
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 13
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Left ankle pain
Swelling to left ankle, + pedal pulses, crushed wound to left ankle
PHYSICAL FINDINGS:
Resp: 24
Pulse: 102
BP: 122/80
OTHER PATIENT INFORMATION:
Tearful, anxious, unable to walk
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-2017 Scenario #: 14
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Difficulty/pain opening mouth
Edema/facial asymmetry, numbness to lower lip
Mandibular Fracture
PHYSICAL FINDINGS:
Resp: 17
Pulse: 112
BP: 130/76
OTHER PATIENT INFORMATION:
Alert and responsive
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name:___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
3. On which unit were you a victim? _________________________
4. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-17 Scenario #: 15
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Right leg injury
Crushed tibia
PHYSICAL FINDINGS:
Resp: 19
Pulse: 122
BP: 144/88
OTHER PATIENT INFORMATION:
Alert, responsive, nervous
Wants to know where his family members are
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History: Trapped under falling debris for several hours.
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
EXERCISE “VICTIM”
SYMPTOMATOLOGY TAG
Date of Exercise: 11-2-17 Scenario #: 16
Tag #: __________
Triage Color: _____________
CHIEF COMPLAINT/VISIBLE SYMPTOMS:
Pain left hand
4th and 5th digit gone
PHYSICAL FINDINGS:
Resp: 18
Pulse: 80
BP: 126/87
OTHER PATIENT INFORMATION:
Responsive, but won’t talk
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
PATIENT INFORMATION:
Name: ___________________________________
Patient Age: Sex:
History:
Actor Exercise Assessment Form
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.
Facility
1. On which unit were you a victim? _________________________
2. Once the exercise began, 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
Exercise Design:
Did you observe any problems during your participation in the exercise? What improvements in response would you suggest?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Any positive comments regarding the facility response should be described below:
________________________________________________________
_____________________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
DO NOT LOSE THIS CARD!
DO NOT LET ANYONE TAKE THIS CARD FROM YOU!
Thank you for your participation!
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