SITREP6 (FACILITY SYSTEM SITUATION REPORT) - MENDO CUSTOM FORM

A. SEND TO:

B. ATTENTION:

C. DATE ENTERED

D. TIME

E. SENT BY

1. INCIDENT NAME:
2. DATE TIME
3. FACILITY NAME TYPE: HOSPITAL    CLINIC   SNF    OTHER
4. CONTACT INFORMATION:
    a) NAME:
    b) PHONE #:
    c) CELL #:
    d) EMAIL:
5. FACILITY OPERATING STATUS (SELECT ONE ONLY):
    A NORMAL B MODIFIED  C LIMITED  D IMPAIRED E NOT FUNCTIONAL  F UNKNOWN
6. OPERATIONAL COMMUNICATIONS SYSTEMS (CHECK ALL THAT APPLY):
    A EMAIL
    B LANDLINE
    C FAX
    D EMSYSTEMS
    E CELL PHONE
    F SATELLITE PHONE
    G MEDNET RADIO
    H HAM RADIO
7. COMPROMISED UTILITY SYSTEMS (SELECT ONE ONLY PER SYSTEM IF COMPROMISED)
        7.1 POWER:  A MODIFIED  B LIMITED  C IMPAIRED  D NON-FUNCTIONAL 
        7.2 WATER:  A MODIFIED  B LIMITED  C IMPAIRED  D NON-FUNCTIONAL
        7.3 SANITATION:  A MODIFIED    B LIMITED   C IMPAIRED   D NON-FUNCTIONAL
        7.4 HVAC:   A MODIFIED   B LIMITED   C IMPAIRED   D NON-FUNCTIONAL
8. EVACUATION STATUS: (SELECT ONE ONLY)
    A NOT EVACUATING
    B PARTIAL ANTICIPATED
    C PARTIAL IN PROGRESS
    D PARTIAL COMPLETED
    E TOTAL ANTICIPATED
    F TOTAL IN PROGRESS
    G TOTAL COMPLETED
    H SHELTER IN PLACE ANTICIPATED
    I SHELTER IN PLACE IN PROGRESS
    J SHELTER IN PLACE COMPLETED
9. CASUALITIES:   ENTER NUMBER PER TRIAGE CATAGORY
      A IMMEDIATE   
      B DELAYED       
      C MINOR             
      D FATALITIES     
10a. DISASTER PLAN ACTIVATED? YES NO
10b. COMMAND CENTER ACTIVATED? YES NO
10c. EMERGENCY POWER IN USE? YES NO
10d. RESOURCE REQUEST PENDING? YES NO

PURPOSE: Provide standardized method for Mendocino County Health Drills to report Status. Origination: All Positions HICS
Original to receiver. Copies to: Documentation Unit Leader and Message Taker