**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?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
b.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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="3.0875in" height="1.3458333333333334in"}

*Apply another label 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

b.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
c.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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="3.0875in" height="1.3458333333333334in"}

*Apply another label 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

c.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
d.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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="3.0875in" height="1.3458333333333334in"}

*Apply another label 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

d.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
e.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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="3.0875in" height="1.3458333333333334in"}

*Apply another label 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

e.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
f.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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="3.0875in" height="1.3458333333333334in"}

*Apply another label 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

f.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
g.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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="3.0875in" height="1.3458333333333334in"}

*Apply another label 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

g.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
h.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

h.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
i.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

i.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
j.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

j.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
k.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

k.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
l.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

l.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
m.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

m.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
n.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

n.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
o.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

o.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
p.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

p.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
q.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

q.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
r.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label 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

r.  How long did it take response personnel to contact you?
    \_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
s.  How long did it take response personnel to begin decontaminating
    you? \_\_\_\_\_\_\_\_\_\_\_\_

> c\. Were you examined on the scene more than once?  Yes  No
>
> d\. Who did you talk to, or whom were you assessed by (list all)? 
> Fire  EMS  Police  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> e\. If you received a multi-colored Triage Tag, what was the BOTTOM
> color when it was first given to you?  Green  Yellow  Red\
>  Black  Never received a Tag
>
> f\. What actions did response personnel take as a result of their
> assessment of your condition?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Treatment:

> a\. If conscious, did someone explain your treatment?  Yes  No
>
> b\. If conscious, were you given clear instructions?  Yes  No
>
> c\. What treatment was given?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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!**

*Apply another label here for additional exercise*

*information \-- Meal, Transportation, Check-Out, etc.*