HSEEP Actor Information Sheet and Waiver Form http://memoryholeblog.com/2013/04/30/hseep-actor-information-sheet-and-waiver-form/#more-4132
Actor Information Sheet
The Actor Information Sheet should be distributed to actors before the exercise and should accompany the Actor Waiver Form. This information sheet is provided as an example only and should be modified to suit the jurisdiction’s needs as well as the exercise scope, type, and scenario. For example, if decontamination will not be part of the exercise, actors do not need to be instructed to wear bathing suits.
Please read and understand the following points;
they will ensure that your participation in this exercise will be safe
and enjoyable. If you have any questions, please contact [Actor POC].
1. The day will be long and tiring.
You need to be at the site by [time], and you will probably not finish until after [time]. If you have any health concerns or medical conditions, please tell [Actor POC] before the start of the exercise. Health or medical concerns will not necessarily disqualify you from participating.
2. You must be at least 18 years old and sign a waiver to participate.
If you are not 18 and are not in the military, parental permission is required to participate. The waiver form (included) must be turned in before the exercise to [Actor POC].
3. Eat a good breakfast before arrival.
It is your responsibility to eat a well-balanced meal before arriving at the exercise, [just in case you miss some of the food provided.]
[Exercise
officials are planning a snack and limited beverages before the
exercise. Volunteers transported to hospitals will be given a snack
before being returned to the exercise site. Volunteers who do not leave
the exercise site will be released before lunch.]
4. Transport yourself to and from the exercise site.
You are responsible to transport yourself to [exercise location].
A map is attached for your convenience. If you carpool with another
volunteer, there is no guarantee that you will be returned to the
exercise site at the same time.
5. Be on time!
Please do not arrive late. It is difficult to begin the exercise if actors are not in place.
You will most likely be released by [time]. However, you may finish earlier or later. Volunteers transported to hospitals will be returned to the exercise site.
6. Wear layers of old clothes and a bathing suit.
Wear clothes that can be removed and a bathing
suit underneath. Wear clothes that you do not mind getting wet, dirty,
stained, or torn. You will get wet.
7. There will be no place to keep personal belongings.
Bring your driver’s license, keys, and a sense of
humor. Do not bring cameras, jewelry, items you don’t want to get wet,
large sums of money, or uninvited friends or volunteers.
8. Don’t overact.
It is very important to play your assigned role
the best you can, but this does not mean you should overact. Overacting
can be dangerous for yourself and the emergency workers in the exercise.
When you arrive at the exercise site, you will be assigned an injury or role and will be briefed about your roles and what will happen during the exercise.
If you do not know how to play your role or have questions about the
briefing, ask the volunteer coordinators. If you are assigned the role
of a psychologically distressed person, please act upset, not out of
control.
9. If you get hurt or have a real problem, say “This is a real emergency.”
You must use the phrase “This is a real
emergency” to tell exercise staff members that you have a real problem
and are not just acting.
10. You must check in and sign out.
When you arrive in the morning, you will sign in and be assigned an “injury.”
A victim tag will be placed around your neck. This card must be
returned at the checkout station. Do not remove or allow anyone to
remove this victim tag during the exercise, even at the hospital. When the exercise is over, return your victim tag with the questions completed on the back.
Please be sure you understand all of these points. If you have any questions, please contact [Actor POC]. We would like to ensure your safety and preparedness for this exercise.
On behalf of [Agency/Jurisdiction]
and all of the participants in the exercise, thank you for
volunteering. It will be an interesting and enjoyable day and, as a
result, our community will be better prepared to face real challenges in
the future.
[Protective Marking]
Homeland Security Exercise and Evaluation Program (HSEEP)
[Full Exercise Name]
Actor Information Sheet [Exercise Name Continued]
AREA MAPS
Figure 1. [Map Title]
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Figure 2. [Map Title]
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Figure 1. [Map Title]
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Figure 2. [Map Title]
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[Protective Marking]
Homeland Security Exercise and Evaluation Program (HSEEP)
[Full Exercise Name]
Actor Waiver Form [Exercise Name Continued]
Actor Waiver Form
On behalf of [Jurisdiction], we thank you for volunteering to be a simulated casualty for our preparedness exercise. The event is scheduled for [date]. Actors should report to [location] at [time].
Exercise Overview
You will be participating as a mock victim of a [scenario].
You will be triaged and either directed or taken to an area where
appropriate decontamination will occur, potentially including cutting of
your clothing. You will be washed and reclothed. Alternative garments
will be provided. Please wear a bathing suit, shorts, and T-shirt, and bring a change of clothes and towel. We would appreciate your wearing loose-fitting and easily removable shoes. It is recommended that you do not wear jewelry.
Jewelry and personal items will be removed during the decontamination
process, bagged, and given to you to carry as you go through the
decontamination line.
Before the event, you will be given a complete
orientation to the incident site, the type of injury or symptoms you
should simulate, and what actions are expected of you.
Please eat a meal and drink plenty of liquids
before you come. After the event, food and refreshments will be
available for you. Restrooms also will be available for your
convenience.
Please Print Name, Sign, and Date
I, _______________________________________, agree to participate in the [sponsor name]-sponsored exercise on [conduct date]. I agree to go through the decontamination process. I will hold harmless [Jurisdiction]
and any other agency or its members participating in this exercise. I
understand that all reasonable and customary safety measures will be
performed to try to prevent injury or harm to me.
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Signature:
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Date:
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Signature of parent or guardian (if under 18):
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Date:
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[Section Title] 1 [Jurisdiction]
[Protective Marking]
[Protective Marking]
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