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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