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. Question Title * 1. Hospital or EMS Agency: Question Title * 2. This exercise was a valuable learning opportunity for our personnel. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Other (please specify) Question Title * 3. Position of person completing survey: EMR, EMT, or Advanced EMT Paramedic Crew Chief/Crew Leader Shift Leader Battalion Chief, District Chief, or EMS Shift Leader Department Head Nurse Other (please specify) Question Title * 4. Hospital Shift or EMS Unit (optional) Question Title * 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? Question Title * 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? Question Title * 7. HOSPITALS ONLY: Were there EMS agencies that did not participate, i.e., who consistently brought patients without a ribbon or tag? Which agencies? 1 2 3 4 5 Question Title * 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? 1 2 3 4 5 Question Title * 9. HOSPITALS ONLY: approximately how many radio calls did you receive from EMS on HSR3-MCI (or HSR6-MCI)? Question Title * 10. For both hospitals and EMS: Were there any issues or challenges with use of the MCI radio talk groups? Question Title * 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? 1 2 3 4 5 Question Title * 12. Did your hospital or EMS agency use OHTrac during this Quarterly Triage Day Drill? Yes, for every patient Yes, for some patients each shift Yes, for just a few patients Yes, but we encountered difficulties No Question Title * 13. Further Comments, Questions, or Concerns regarding Quarterly Triage Days: Done