Soin Medical Center and Greene Memorial Hospital FSE Controller Evaluator Sign-Ups

On Sunday, August 25th from 10:00 AM-5:00 PM, Dayton MMRS will be putting on a mass casualty exercise hosted by Kettering Health Network facilities. We are looking for people to serve as Controller/Evaluators in these exercises. If you are interested, please fill out your information in the survey below. Thank you.

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* Where would you be able to serve as a Controller/Evaluator?
(Select all that apply)

Soin Medical Center - Beavercreek

Greene Memorial Hospital - Xenia

No preference

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* Controller/Evaluator Information
Last Name:

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* First Name:

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* E-Mail:

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* Confirm E-Mail:

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* Phone Number:

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* I would be comfortable serving as a controller/evaluator in the following areas:
(Select all that apply)

Law Enforcement

EMS

RTF

Anesthesia

ICU/PACU

Blood Bank

Respiratory

HICS/Administration

Labs

Radiology/Imaging

Security

Environmental Services

Labor and Delivery

Victim Controllers

Simulation Cell

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* Where would you be able to serve as a Controller/Evaluator?(Select all that apply)

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* Controller/Evaluator InformationLast Name:

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* First Name:

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* E-Mail:

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* Confirm E-Mail:

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* Phone Number:

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* I would be comfortable serving as a controller/evaluator in the following areas:(Select all that apply)

* Where would you be able to serve as a Controller/Evaluator?
(Select all that apply)

* Controller/Evaluator Information
Last Name:

* I would be comfortable serving as a controller/evaluator in the following areas:
(Select all that apply)