1. Incident Name 2. Operational Period (# ) DATE: FROM: _ TO: _ TIME: FROM: _ TO: _ 3. Section Section Chief 4. Branch (if applicable ) Branch Director 5a. Branch / Unit Related Objectives 5b. Strategies / Tactics 5c. Resources Required 5d. Unit Assigned to Purpose: Documents strategies/tactics of each Section or Branch, resources to accomplish them, and the composition of the Unit assigned Origination: Each Section Chief and Branch Director activated Copies to: Command Staff, Section Chiefs, and Documentation Unit Leader HICS 204 | Page 1 of 2
1. Incident Name 2. Operational Period (# ) DATE: FROM: _________ TO: TIME: FROM: _ TO: 3. Name of Facility / Building Reporting Status Below 4. System 5. Status 6. Comments If not fully functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected. COM M UNICATIONS Fax  Fully functional  Partially functional  Nonfunctional  N/A Information Technology System Email, registration, patient records, time card system  Fully functional  Partially functional  Nonfunctional  N/A Nurse Call System  Fully functional  Partially functional  Nonfunctional  N/A Overhead Paging  Fully functional  Partially functional  Nonfunctional  N/A Paging System Code teams, standard paging  Fully functional  Partially functional  Nonfunctional  N/A Radio Equipment Facility handheld, 2-way radios, antennas  Fully functional  Partially functional  Nonfunctional  N/A Radio Equipment EMS, local health department, other external Partner  Fully functional  Partially functional  Nonfunctional  N/A Radio Equipment Amateur radio  Fully functional  Partially functional  Nonfunctional  N/A Satellite Phones  Fully functional  Partially functional  Nonfunctional  N/A Purpose: Determine facility operating status Origination: Infrastructure Branch Director Copies to: Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, Safety Officer, Liaison Officer, Materiel Tracking Managers, and Documentation Unit Leader HICS 251 | Page 1 of 6
Laundry/Linen Service Equipment  Fully functional  Partially functional  Nonfunctional  N/A Structural Components Building integrity  Fully functional  Partially functional  Nonfunctional  N/A (Note cracked walls, loose masonry, hanging light fixtures, broken windows) PATIENT CARE Decontamination System Including containment  Fully functional  Partially functional  Nonfunctional  N/A Digital Radiography System, Routine Diagnostics PACS, CT, MRI, other  Fully functional  Partially functional  Nonfunctional  N/A Steam/Chemical Sterilizers  Fully functional  Partially functional  Nonfunctional  N/A Isolation Rooms Positive/negative air  Fully functional  Partially functional  Nonfunctional  N/A SECURITY Facility Lockdown Systems Door/key card access  Fully functional  Partially functional  Nonfunctional  N/A Campus Security External panic alarms  Fully functional  Partially functional  Nonfunctional  N/A Campus Security Surveillance cameras  Fully functional  Partially functional  Nonfunctional  N/A Campus Security Traffic controls  Fully functional  Partially functional  Nonfunctional  N/A Purpose: Determine facility operating status Origination: Infrastructure Branch Director Copies to: Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, Safety Officer, Liaison Officer, Materiel Tracking Managers, and the Documentation Unit Leader HICS 251 | Page 3 of 6
HICS 254 – DISASTER VICTIM / PATIENT TRACKING 1. Incident Name 2. Operational Period (# ) DATE: FROM: TO: TIME: FROM: _ TO: 3. Area (Triage or Specific Treatment Area) FIELD TAG NUMBER MEDICAL RECORD NUMBER NAME (LAST NAME, FIRST NAME) SEX (M/F) DOB / AGE TRIAGE CATEGORY IMMEDIATE DELAYED MINOR EXPECTANT EXPIRED LOCATION / TIME OF PROCEDURES (CT, X-RAY, ETC.) DISPOSITION / TIME (D) DISCHARGE (A) ADMIT (S) SURGERY (T) TRANSFER (M) MORGUE 4. Prepared by PRINT NAME: SIGNATURE: DATE/TIME: FACILITY: _ Purpose: Records the triage, treatment, and location of victims/patients Origination: Patient Tracking Manager or team Copies to: Situation Unit Leader, Patient Registration Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and Documentation Unit Leader HICS 254 | Page 1 of 1
HICS 255 - MASTER PATIENT EVACUATION TRACKING 1. Incident Name 2. Operational Period (# ) DATE: FROM: TO: TIME: FROM: TO: 3. Patient Evacuation Information PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) 4. Prepared by PRINT NAME: SIGNATURE: DATE/TIME: FACILITY: Purpose: Record information concerning patient disposition during an evacuation Origination: Situation Unit Leader or designee (Patient Tracking Manager) Copies to: Planning Section Chief, Documentation Unit Leader . HICS 255 | Page 1 of 1