SITUATION REPORT QUICKSHEET
INSTRUCTIONS REPORT TYPE
1. Watch for CAHAN or Image Trend alert with Health Department instructions. Watch for Image Trend polls.
2. Submit this QuickSheet within 1 hour of your Command Center activation to MHOAC.

MHOAC Email: MHOAC@mendocinocounty.org         MHOAC Fax: 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   
CONDITION
CONDITION
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. Add a page if necessary. Check here if attaching an extra page 
5. FACILITY OPERATING STATUS      If reporting by voice, speak only line 5 and a single status letter
Check ability to provide essential care services.   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  
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
Rev.September 2022 Formatted for digital or voice transmission May 2024