EMS OHTrac Participant Questionnaire 1. Question Title * 1. Name of Agency Question Title * 2. Address of Agency Question Title * 3. What County does your agency reside in? Question Title * 4. Agency Point of Contact Name Question Title * 5. Agency Point of Contact Contact Email Address Question Title * 6. Agency Point of Contact Phone Number Question Title * 7. Number of Staff at your Agency Question Title * 8. Number of BLS Ambulances at your Agency Question Title * 9. Number of ALS Ambulances at your Agency Question Title * 10. Does your Agency currently use OHTrac? Yes No Question Title * 11. If your Agency has an OHTrac account and doesn't use it please select why. Unknown Benefit Financial Obligations Triage Tags used by the Agency can't be scanned Device is not Compatible Low Priority Limited Trained Staff Cell Phone Usage Limited Wi-Fi Patient tracking for family reunification is not the role of EMS Limited manpower/personnel Limited experience with Mass Casualty Incidents No device Other (please specify) Question Title * 12. If you have Trained Staff at your Agency why are they not using OHTrac? Unknown Benefit Financial Obligations Triage Tags used by the Agency can't be scanned Device is not Compatible Low Priority Cell Phone Usage Limited Wi-Fi Patient tracking for family reunification is not the role of EMS Limited manpower/personnel Limited experience with Mass Casualty Incidents No device Limited trained staff Other (please specify) Question Title * 13. Will your Agency continue to use or start using OHTrac in the future? Yes No Question Title * 14. If you have previously used OHTrac, do you feel the training materials will change how you use it? Yes No N/A Question Title * 15. If you don't plan to use OHTrac in your Agency, please select why? Personal Cell Phone Usage Limited WiFi Not the Role of EMS Limited Manpower Limited Experience with a Mass Casualty Incident (MCI) Unknown Benefit Financial Obligations Triage Tags used by the Agency can't be scanned Low Priority No Scanning Device Scanning Device is not Compatible Limited Trained Staff Other (please specify) Question Title * 16. Does your Agency plan to conduct or participate in drills using OHTrac Yes No N/A Question Title * 17. Why will your Agency not use OHTrac during drills/exercises? Personal Cell Phone Usage Limited Wifi Unknown Benefit Not the Role of EMS Limited Manpower Lack of Experience with a Mass Casualty Incident (MCI) Financial Obligation Agency doesn't have Triage Tags Agency doesn't have a Scanner Agency doesn't have an OhioEMS Issued Tablet Limited Trained Staff Low priority Other (please specify) Question Title * 18. Please add any additional comments or barriers related to OHTrac. Question Title * 19. Please type your full name to indicate that you are aware that OHTrac exists in the State of Ohio, and to acknowledge that if your Agency wants to use OHTrac a Confidentiality Form will need to be signed by your Agency Head. Done