**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.796527777777778in"
height="1.21875in"}![](media/image2.wmf){width="2.7979166666666666in"
height="1.21875in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.796527777777778in"
height="1.21875in"}![](media/image2.wmf){width="2.7979166666666666in"
height="1.21875in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7465277777777777in"
height="1.1972222222222222in"}![](media/image2.wmf){width="2.748611111111111in"
height="1.1972222222222222in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7465277777777777in"
height="1.1972222222222222in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7465277777777777in"
height="1.1972222222222222in"}![](media/image2.wmf){width="2.748611111111111in"
height="1.1972222222222222in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7930555555555556in"
height="1.2173611111111111in"}![](media/image2.wmf){width="2.7979166666666666in"
height="1.21875in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7465277777777777in"
height="1.1972222222222222in"}![](media/image2.wmf){width="2.748611111111111in"
height="1.1972222222222222in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7465277777777777in"
height="1.1972222222222222in"}![](media/image2.wmf){width="2.748611111111111in"
height="1.1972222222222222in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*

**EXERCISE "VICTIM"**

**SYMPTOMATOLOGY TAG**

**Date of Exercise: \_\_\_\_\_\_\_\_\_\_\_\_ Casualty #:
\_\_\_\_\_\_\_\_**

**VISIBLE SYMPTOMS:**

**PHYSICAL FINDINGS:**

**OTHER PATIENT INFORMATION:**

**Actor Exercise Assessment Form**

Please complete the following questions at the conclusion of the
exercise. This card is to be turned in at the Check-Out Station, at the
exercise site. Please be accurate with your answers. Your cooperation is
important and is appreciated.

**[Field Assessment and Treatment:]{.underline}**

**1.** Initial Contact & Triage:

> **a.** How long did it take response personnel to contact you?
> \_\_\_\_\_\_\_\_
>
> **b**. How long did it take for 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 who 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  Yellow  Red\
>  Black  Never received a Tag
>
> **f.** Where you taken or directed after Triage?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Treatment:

> **a.** If conscious, did someone explain your treatment?  Yes  No
>
> **b.** If conscious, were you given clear instructions?  Yes  No
>
> **c.** What actions did response personnel take as a result of their
> assessment of your condition? What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3.** Did you observe any outstanding actions among the response
personnel you observed?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Hospital (if applicable)]{.underline}**

**1.** Which hospital did you go to?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** Once at the hospital, how long until someone examined you?  Less
than 5 minutes  5 minutes  10 minutes  15 minutes  Over 15 minutes 
I was never examined at the hospital

**[Exercise Design:]{.underline}** Did you observe any problems during
your participation in the exercise? What improvements would you suggest?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DO NOT LOSE THIS CARD!!**

**DO NOT LET ANYONE TAKE THIS CARD FROM YOU!**

![](media/image1.wmf){width="2.7465277777777777in"
height="1.1972222222222222in"}![](media/image2.wmf){width="2.748611111111111in"
height="1.1972222222222222in"}

*Apply Label #4 here for additional*

*exercise information \-- Meal,*

*Transportation, Check-Out, etc.*