Trauma Simulation Intake Form
Please provide scenario details and participant information for trauma simulation intake.
Date of Simulation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Simulation Scenario Type
*
Please Select
Blunt Trauma
Penetrating Trauma
Burns
Mass Casualty
Other
Participant Role
*
Team Leader
Primary Assessor
Airway Manager
Circulation Manager
Recorder
Other
Simulated Patient Age Group
*
Pediatric
Adult
Geriatric
Initial Triage Level
*
Immediate (Red)
Delayed (Yellow)
Minor (Green)
Expectant (Black)
Primary Injury or Condition
*
Please Select
Head Injury
Chest Trauma
Abdominal Injury
Fractures
Burns
Other
Initial Vital Signs (enter as text, e.g., HR: 90, BP: 120/80, RR: 16)
*
Planned Interventions
*
Airway Management
IV Access
Fluid Resuscitation
Hemorrhage Control
Splinting
Medication Administration
Other
Simulation Learning Objectives
*
Submit Intake
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