Emergency Preparedness Exercise Volunteer Solicitation

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Volunteer to Help the Metroplex Prepare!

Emergency Preparedness Exercise

Volunteer Solicitation

More than 2, 500 volunteers are needed!

WHEN: Monday, November 15 (times vary by assigned location)

WHERE: Texas Motor Speedway and area hospitals

The Tarrant County Public Health Department, Defenbaugh & Associates and the University of North Texas Health Science Center at Fort Worth Office of Professional and Continuing Education need your help.

Together, we are planning a first-of-its-kind exercise that will provide an in-depth assessment of the region's readiness to respond to a mass casualty event. The exercise will realistically simulate a terrorist attack and will involve dozens and local, state and federal organizations, including police, fire and other first responders,

hospitals, area public health departments, as well as state and federal emergency and law enforcement agencies.

More than 2500 volunteers are needed to make the simulation as realistic as possible and to test the ability of facilities to respond effectively when faced with large numbers of injured, scared or panicked patients. Volunteers will be assigned locations and times to arrive on Monday, Nov. 15th, along with specific instructions on how to act, what to do, etc.

Each volunteer is required to complete the registration form and sign the informed consent and parental consent, if applicable. You may register online at at

http://www.IWillVolunteer.com.

CE Credits available for medical professionals who volunteer!

The University of North Texas Health Science Center at Fort Worth Office of

Professional and Continuing Education will accredit this activity for physicians, nurses, social workers and other health professionals. You will receive a notice after you register on the objectives, number of credits/hours and other CME/CE information. If you are interested in this free option, be sure to check the "I request CME/CE

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Volunteer to Help the Metroplex Prepare!

Registration Form

(Register online at http://www.IWillVolunteer.com)

First Name MI Last Name

E-mail

Date of Birth Age *If under 18, parental consent required, see pg. 2

Day Phone Evening Phone

Organization or Company Credentials (MD, DO, RN, etc.) Miles willing to travel

Check here if you are interested in CME/CE information ‰ Emergency

Contact Name

Emergency

Contact Phone: Relationship

Please describe any medical and/or clinical experience you have Please describe any special need you may have

Please read and complete the informed consent and (if

applicable) the parental/guardian consent form on the

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Informed Consent for Potential Volunteers

Please read the following important information regarding your potential participation as a volunteer for the November 15, 2004 exercise:

Purpose:

The exercise will test preparedness for a major terrorist event that, if real, would require response from many participating agencies at the local, regional, state and federal levels. The goal is to evaluate the flow of information among participating agencies, test communications systems, and monitor adherence to desired procedures.

What you should expect as a volunteer:

Logistical details: Before the exercise, you’ll be informed of the location to which you’ve been assigned. At least three days before the exercise begins, you’ll receive information in writing, via e-mail or regular mail, about when you should arrive, where to park, and anything else you should know in advance, including anticipated weather conditions, appropriate attire and an estimate of the time required for your participation.

Time required: Most volunteers will be needed for at least two hours; some could be

needed for as many as five hours.

Specific assignment and nature of activities: After you report to the volunteer

coordinator at your assigned location, you’ll receive further details about your

assignment. While exercise activities vary by location, volunteers will generally be used to either play the role of an injured victim at Texas Motor Speedway or the role of a potential patient arriving at an area hospital. Some volunteers will also play the role of uninjured spectators or “worried well.” Tasks likely to be associated with these roles could include frequent sitting, pushing/pulling, crouching/stooping, squatting, standing and walking. Some volunteers may be asked to lay down on the ground or pavement, slump down in a specific position on the ground or an assigned seating area, walk in a manner to suggest a limp or injury, apply makeup for the same purpose, climb up or down stairs, or receive simulated patient care. (Volunteers will not receive any type of actual medical treatment related to the planned exercise.) Volunteers assigned to Texas Motor Speedway should also expect to see a simulation of the terrorist scenario that’s planned for this exercise as well as the arrival and activation of emergency response vehicles and crews.

Who should not participate: Potential volunteers who have any health problems that

might be incompatible with the physical demands described above, including respiratory or cardiovascular difficulties, or pregnancy, should not participate or should consult a physician before volunteering.

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Your rights as a volunteer:

• Your participation in this exercise is absolutely voluntary; you will not be paid for participating.

• You may decide to halt your participation at any time, for any reason, simply by notifying your assigned volunteer coordinator that you do not wish to continue. In addition, you may request at any time to be reassigned to a different volunteer task or location. Your request will be accommodated, if possible.

Your responsibilities as a volunteer:

• You will need to use your personal vehicle for travel to and from your assigned location.

• If you register to participate, but then decide not to participate before November 15, provide as much notice as you can by contacting the project coordinator (see contact information at the end of this page).

• Tell us in advance (via the registration form) if you have any health or medical conditions that could limit or prohibit your full participation in the exercise or if you have any other special needs.

• If you wish to halt your participation during the exercise, inform your volunteer coordinator before you leave.

• If you are under 18 years of age and wish to volunteer, you must first complete a parental consent form and indicate the names of one or more adults who will accompany you during the exercise.

• To participate, you must indicate that you have read and understand the information on this page.

I certify that I have read and understand the foregoing information and agree to fulfill my responsibilities as a volunteer in the November 15, 2004 emergency preparedness exercise.

Printed Name_______________________

Signature__________________________ Date_________________

Contact information: If you have any questions or need to withdraw your voluntary

participation in this exercise, please contact the project coordinator, Andy Crim. You can reach Andy by calling him at (817) 735-2644 or via e-mail to: acrim@hsc.unt.edu.

Return this completed form before November 8 to: Andy Crim

FAX: 817-735-2598

Phone: 817-735-2539

Mail: PACE Office

3500 Camp Bowie Blvd. Fort Worth, TX 76107

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Parental/Guardian Consent Form

(To be completed for all volunteers under 18 years of age)

If you are under 18 and wish to volunteer for the field functional exercise mock disaster drill on November 15, 2004, this form must be on file no later than

November 8th.

Dear Parent:

Your child has volunteered to participate in a mock disaster exercise on Monday, November 15, 2004. Your child's participation in this exercise is voluntary and, therefore, not compensated. Your child’s name will not be used in the promotion or reporting of the exercise. Your child will be assigned a location, generally a health care facility, and detailed instructions. By signing below, you are consenting to permit your child to participate in this exercise.

I am the parent/guardian of____________________________________(child’s name) and give my consent that he/she may participate in the mock disaster exercise on Monday, November 15, 2004.

Names of one or more adults who will accompany the minor during the exercise: ___________________________________________________________________ ___________________________________________________________________

________________________ __________________________

(parent/guardian printed name) (today’s date)

_________________________ __________________________ (parent/guardian signature) (parent/guardian phone number) Return this completed form before November 8 to:

Andy Crim FAX: 817-735-2598 Phone: 817-735-2539 Mail: PACE Office 3500 Camp Bowie Blvd. Fort Worth, TX 76107

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