SITUATION REPORT (Short HICS251)

NUMBER
TITLE
INSTRUCTIONS
1 Incident Name Enter the name assigned to the incident.
2a & 2b Operational Period Enter the start date (m/d/y) and time (12 hour clock) and end date and time.
3a & 3b Facility Name &
Type
Enter the name of the facility and type
4a , 4b,
4c & 4d
Contact Info Contact name, phone, cell phone and email
5 Status Normal: 100% operable with no limitations
Modified: Operable or somewhat operable with limitations
Limited: Partial functional some assistance needed
Impaired: Major assistance needed
Not functional: Major assistance needed
Unknown: Not applicable, do not have info
6 Communications Email, land line phone, fax, internet, cell phone, satellite phone, amateur radio
7 Utilities Power, water, sanitation, heating, A/C, ventilation
8 Evacuation Evacuating: Partial evacuation, Total evacuation, Shelter in Place.
9 Impact/Casualties Immediate (Red): Critical care
Delayed (Yellow): Moderate care
Minor (Green): Care not needed immediately
Fatality (Black): Deceased
10 Additional Information Internal disaster plan activated?
Facility Command Center activated?
Emergency generator power in use?

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    HOSPITAL STATUS REPORT  (Short HICS 251)
     

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Report Type (check one)
Initial   Update #      Final

1. Incident Name 2a. Date: 2b Time:
3a. Facility Name 3b. Facility Type Hospital    Clinic    LTCF   Other, specify:
4a. Contact Name 4b. Contact Phone    X   
4c. Cell Phone 4d. Contact Email Address
5. FACILITY OPERATING STATUS
 Normal  Modified partially functional - no assistance needed (explain)  Limited partially functional,- Some assistance needed (explain)  
 UNKNOWN  Impaired- major assistance needed (explain)  Not functional major assistance needed (explain)
Check ability to provide essential care services NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
6. COMMUNICATIONS
  Email NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
  Landline Phone NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
  Fax NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
  Internet NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
  Cell Phone NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
  Satellite Phone NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
  Amateur Radio NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
7. UTILITIES
Power NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
Water NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
Sanitation NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
Heating/Ventilation/AC NORMAL MODIFIED LIMITED IMPAIRED NOT FUNCTIONAL UNKNOWN
8. EVACUATION
Evacuating?   YES       NO IF Yes, evacuation is: Anticipated   In progress   Completed
Partial Evacuation   YES       NO IF Yes, evacuation is: Anticipated   In progress   Completed
Total Evacuation   YES       NO IF Yes, evacuation is: Anticipated   In progress   Completed
Shelter in place   YES       NO IF Yes, evacuation is: Anticipated   In progress   Completed
9. IMPACT/CASUALTIES–provide estimated numbers and any comments:
Immediate injuries = Critical care needed RED   Estimated #  
Delayed injuries = Moderate care needed YELLOW   Estimated #
Minor injuries = Care not needed immediately GREEN   Estimated #
Fatalities BLACK = Deceased   Estimated #
10. ADDITIONALINFORMATION:
Internal disaster plan activated? YES       NO Facility Command Center activated? YES     NO
Emergency generator power in use? YES       NO Will you send Resource Request within 4 hours? YES      NO

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