Omaha Nebraska NEED TO KNOW

Omaha Nebraska NEED TO KNOW    

Below is copied from PDF I found

www.ommrs.org/documents/volunteerConsentForm.doc
 

Omaha Metropolitan Medical Response System (OMMRS)

Full Scale Evacuation Exercise

October 16th, 2013

12:00 to 5:00PM

Volunteer Participant Release Form

On behalf of the Omaha Metropolitan Medical Response System (OMMRS) we want to thank you for volunteering to be a simulated actor and exercise participant for our Full Scale Evacuation Exercise scheduled for Wednesday October 16th. 2013. from 12:00 noon to 5:00 PM.

You will be participating as a mock patient or family member involved in a hospital evacuation scenario.
This exercise will assist in assessing the community ability to handle an evacuation event.   Additionally, please dress according to the forecasted weather conditions. We would appreciate your wearing comfortable clothing and shoes.  It is recommended that jewelry, cell phones, pagers and other valuables be left at home. There will not be a location to secure your personal valuables and OMMRS is not able to repair or replace any lost or damaged items.

Before the event, you will be given a complete orientation to the incident site, the type of diagnosis or symptoms you should simulate and what actions are expected of you.
Please eat a meal and drink plenty of liquids before you come. 

I _______________________________________ agree to participate in the Omaha Metropolitan Medical Response System, Full Scale Evacuation Exercise.  I agree to simulate the patient diagnosis and symptoms as presented to me..  I will ensure that I participate and listen to all safety briefings and adhere to the instructions provided by the exercise safety officers and or exercise controllers. I will hold harmless the Omaha Metropolitan Medical System (OMMRS) and all participating facilities and its members participating in this exercise.  I understand that all reasonable and customary safety measures will be performed to prevent injury or harm.  I grant permission to be photographed and/or videotaped, and to permit others to use the photographs/video without restriction or compensation.  

Signature        Date    

Signature of Parent/Guardian (if under 19)__________________________________

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