18E 2023 Soin Medical Center and Greene Memorial Hospital FSE Controller Evaluator Sign-Ups

On Sunday, April 30th from 11:30 AM-4:00 PM, Dayton MMRS will put on a mass casualty exercise hosted by Kettering Health. We need Controller/Evaluators for these exercises. If you are interested, please fill out the information below. Thank you.

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

Clark State Community College – Greene Center (3775 Pentagon Blvd., Beavercreek)

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 (Very Important: you will receive all information about the exercise via email.):

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* Cell 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 (Very Important: you will receive all information about the exercise via email.):

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* Cell 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)