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QTD Feedback Form

For the Quarterly Triage Day, please provide the following feedback. You may fill this out for a hospital or a shift at a hospital, or for an EMS Agency, or for each EMS Unit, whichever is most appropriate for your case.
1.Hospital or EMS Agency:(Required.)
2.This exercise was a valuable learning opportunity for our personnel.(Required.)
3.Position of person completing survey:
(Required.)
4.Hospital Shift or EMS Unit (optional)
5.For both hospitals and EMS:  Approximately how many patients did YOUR hospital or EMS Agency "triage" (i.e., APPLY triage ribbons and tags to) during the QTD?(Required.)
6.HOSPITALS ONLY:  Approximately how many patients did you receive from EMS during the QTD with a Triage Ribbon and Triage Tag applied by EMS?
7.HOSPITALS ONLY:  Were there EMS agencies that did not participate, i.e., who consistently brought patients without a ribbon or tag? Which agencies?
8.HOSPITALS ONLY:  Were there EMS agencies that consistently did not use the MCI Radio Talk Group during the two hour block for radio usage? If so, which agencies?
9.HOSPITALS ONLY:  approximately how many radio calls did you receive from EMS on HSR3-MCI (or HSR6-MCI)?
10.For both hospitals and EMS:  Were there any issues or challenges with use of the MCI radio talk groups?(Required.)
11.EMS ONLY:  were there hospitals your agency attempted to call on the MCI radio talk group during the two hour block that did not answer the radio call?  If so, which hospitals?
12.Did your hospital or EMS agency use OHTrac during this Quarterly Triage Day Drill?
(Required.)
13.Further Comments, Questions, or Concerns regarding Quarterly Triage Days: