SITUATION REPORT QUICKSHEET

INSTRUCTIONS	REPORT TYPE
1. Watch for CAHAN or EMS systems alert with Health Department instructions. Watch for EMS polls. 2. FAX this QuickSheet within 1 hour of your activation to Health Department DOC at 707-472-2782	Inital Update #   Final
1. Incident Name     2a. Date     2b. Time     3a. Facility Name     3b. Facility Type :  Hospital  Clinic  SNF  Other  4a. Contact Name    4b. Contact Phone     Ext.   4c. Contact Cell Phone     4d. Contact email Address
STATUS REPORTING CODES A = NORMAL Fully Functional   B = MODIFIED   Partially Functional   No assistance needed  C = LIMITED   Partially Functional   Some Assistance  needed (Explain) D = IMPAIRED   Major assistance   needed (Explain) E = NOT FUNCTIONAL   Major assistance   needed (Explain) F = UNKNOWN COMMENTS If not fully functional, give location, reason, estimated time or resources needed for repair or other information. Send a HICS-213 follow-up report if necessary.
FACILITY OPERATING STATUS      If reporting by voice, speak only line 5 and a single status letter 5   Summary Status  _______________ A   B   C   D   E   F   6. COMMUNICATIONS If reporting by voice, speak only the not fully functional item number and a single status letter 6.1    Email __________________________ A   B   C   D   E   F   6.2    Landline Phone ________________ A   B   C   D   E   F   6.3    Fax ___________________________ A   B   C   D   E   F   6.4    EMSystems ______________________ A   B   C   D   E   F   6.5    Cell Phone _____________________ A   B   C   D   E   F   6.6    Satellite Phone ________________ A   C   B   D   E   F   6.7    Med Net Radio (UHF) ____________ A   B   C   D   E   F   6.8    Ham Radio ______________________ A   B   C   D   E   F   7. UTILITIES If reporting by voice, speak only the not fully functional item number and a single status letter 7.1    Power __________________________ A   B   C   D   E   F   7.2    Water __________________________ A   B   C   D   E   F   7.3    Sanitation _____________________ A   B   C   D   E   F  7.4    Heating/Ventilation/AC ___________________ A   B   C   D   E   F   8. EVACUATION If reporting by voice, speak only the item number and Yes or No and the status single word if Yes 8.1    Evacuating? ____________________ Yes  No    If yes,   Anticipated  In progress  Completed 8.2    Partial Evacuation? ____________ Yes  No    If yes,   Anticipated  In progress  Completed     8.3    Total Evacuation? ______________ Yes  No    If yes,   Anticipated  In progress  Completed     8.4    Shelter in Place? ______________ Yes  No    If yes,   Anticipated  In progress  Completed     9. IMPACT / CASUALITIES  If reporting by voice, speak only the item number and the number of estimated casualities 9.1    Immediate injuries = Critical care Estimated # 9.2    Delayed injuries = Moderate care Estimated # 9.3    Minor injuries = Care not needed Estimated # 9.4    Fatalities Estimated # 10. ADDITIONAL INFORMATION If reporting by voice, speak only the item number and Yes or No 10.1    Is internal disaster plan activated?   YES     NO 10.2    Is Command Center activated?   YES     NO 10.3    Is Generator power in use?   YES     NO 10.4    Resource Request within 4 hours?   YES     NO