Form: Hospital_Status_Initial.html, Hospital_Status_Viewer.html
To:
Subject: HOSPITAL SITUATION REPORT From:
SeqInc:
Msg:
HOSPITAL SITUATION REPORT
REPORT INFORMATION:
Email:
Report Type:
1. Incident Name:
2a. Date:
2b Time:
3a. Facility Name:
3b. Facility Type:
4a. Contact Name:
4b. Contact Phone: X
4c. Cell Phone:
4d. Contact Email Address:
5. FACILITY OPERATING STATUS
STATUS definitions:
Normal
Modified partially functional - no assistance needed (explain)
Limited partially functional,- Some assistance needed (explain)
Impaired- major assistance needed (explain)
Not functional major assistance needed (explain)
STATUS:
Comments
6. COMMUNICATIONS
Email:
Landline Phone:
Fax:
Internet:
Cell Phone:
Satellite Phone:
HEART Amateur Radio:
7. UTILITIES
Power:
Water:
Sanitation:
Heating/Ventilation/AC:
8. EVACUATION
Evacuating:
Partial Evacuation:
Total Evacuation:
Shelter in place:
9. IMPACT/CASUALTIES–provide estimated numbers and any comments:
Estimated # Immediate injuries = Critical care needed RED
Estimated # Delayed injuries = Moderate care needed YELLOW
Estimated # Minor injuries = Care not needed immediately GREEN
10. ADDITIONALINFORMATION:
Internal disaster plan activated?
Facility Command Center activated?
Emergency generator power in use?
Will you send Resource Request within 4 hours?
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