Region 1 MCI Full Scale Exercise Organization Participation Form

On September 16, 2025, Region 1 will conduct a full-scale Mass Casualty Incident Exercise at Sherwood Island Park in Westport, CT. This interactive event is designed to assess and enhance local emergency response plans and capabilities.

We invite your organization to participate in this critical training opportunity. Please complete the form below to confirm your organization's involvement—only one submission per organization is required. Submit your completed survey by May 23, 2025

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* 1. Organization Name

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* 2. Organization address

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* 3. Organization Phone Number

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* 4. Organization Contact Name

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* 5. Organization Contact Cell Number

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* 6. Organization Contact Email

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* 7. Will your organization participate in the Region 1 MCI Full Scale Exercise on September 16, 2025?

Yes

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* 8. Anticipated Number of Participants from your organization

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* 9. Please select the area that represents your discipline the best (Select all that apply)

Setup/Breakdown

Food and Refreshments

Staging

Registration

Mock Patient

Triage

Hazmat/Decontamination

Security

Transport to Hospital (and back)

Receipt of Patients at Hospital ER

Media

Incident Command

Communications

Traffic Control

Other (please specify)

Email: Sue Jacozzi at sjacozzi@trumbull-ct.gov if you have any questions.