5. FACILITY OPERATING STATUS If reporting by voice, speak only line 5 and a single status letter |
Check ability to provide essential care services. |
A
B C
D
E F |
6. COMMUNICATIONS
If reporting by voice, speak only the not normal item numbers and a single status letter for each |
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 normal item numbers and a single status letter for each |
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 neeeded |
Estimated # |
9.2 Delayed injuries = Moderate care needed |
Estimated # |
9.3 Minor injuries = Care not needed immediately |
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 |