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SAN DIEGO HOSPITAL STATUS REPORT FORM - Essential Elements  
San Diego County Health Care Disaster Coalition

      Send this form to San Diego County EMS DOC via WebEOC; or fax to Public Health Preparedness & Response Branch (PHPR) at 619-285-6531;
or phone at 619-285-6433; or via ARES-ACS, or messenger.

BLOCK 0       ACTUAL INCIDENT      OR       THIS IS A DRILL

    Form Info     

[0A]  Operational Period:    Date From:     

Date To:      

 Time From:

Time To:    

BLOCK 1 FACILITY ID
[1A]   Facility Name [1B]  Facility City or Neighborhood
[1C]   Facility Street Address    
[1D]   IC Name [1E]  IC Phone
[1F]   Other Contact Name [1G]  Other Contact Phone
[1H-L]   Communications        WebEOC   Commercial Radio   Phone    ARES-ACS    Other:
[1M]   Remarks
BLOCK 2 - CURRENT OPERATIONAL STATUS ( Select One ) BLOCK 3 NEXT OPERATIONAL PERIOD ( Select One )
[2A] Current Operational Status
Fully Functional    Partially Functional    NOT Functional		 [3A] Next Operational Period
Fully Functional   Deteriorating Operations   Considering Evacuation
[2B] Remarks
BLOCK 4 - DAMAGE ASSESSMENT (NO or YES) BLOCK 5 SERVICES- (YES or NO)
[4A] No damage Structural damage Partial collapse Total collapse [5A] All services are available YES    NO
[4B] Evacuating hospital NO    YES [5B] Emergency Department functioning YES    NO
[4C] Internal disaster NO   YES   [5C] Laboratory functioning YES    NO
[4D] Flooding NO    YES   [5D] Operation Rooms functioning YES   NO
[4E] Remarks

 [5E] Pharmacy functioning YES    NO
[5F] Radiology functioning YES    NO
[5G] Nutrition/Environmental functioning YES    NO
[5H] Behavioral Health Unit functioning YES    NO
[5I] Morgue/Mass Fatality Area YES    NO
[5I] Remarks
BLOCK 6 UTILITY STATUS (YES or NO) BLOCK 7 SUPPLY LEVELS ADEQUATE
[6A] All utilities normal YES    NO [7A] Food / Water YES    NO
[6B] Elevator YES    NO [7B] Linen / Laundry YES    NO
[6C] HVAC YES   NO [7C] Medical / Surgical Supplies YES    NO
[6D] Information services (IT) YES    NO [7D] Pharmaceuticals YES    NO
[6E] Natural gas YES    NO [7E] Staffing YES    NO
[6F] Phone YES    NO [7F] Remarks and Supplies Needed
[6G] Water YES    NO
[6H] Waste water/sewer YES    NO
[6I] Electrical Commercial   GeneratorBLOCK 8 HOW LONG WITHOUT ASSISTANCE
[6J] Electrical generator tested YES    NO [8A] Longer then 48 hours Up to 48 hours Up to 12 hours
[6k] Gen fuel status >48 hours   <48 hours    <12 hours   [8B] Remarks
[6L] Remarks
BLOCK 9 - DAMAGE ASSESSMENT BLOCK 10 SURGE                                                          COUNT
Evacuation ("TRAIN" Categories) TOTAL COUNT [10A] Casualty Information (in last 12 hours)
[9A] Ambulatory to Evacuate (blue) [10B] Patients Not Yet Seen
[9B] Basic Life Support (BLS) to Evacuate (green) [10C] Patients Treated and Released
[9C] Advanced Life Support (ALS) to Evacuate (yellow) [10D] Patients Admitted (in last 12 hours)
[9D] Critical Care Transport (CCT) (orange) [10E] Remarks
[9E] Specialized (red)
[9F] Remarks
BLOCK 11 OTHER REMARKS
 
BLOCK 12       
 

  Radio Operator        Name:  Report Date/Time :  

    Facility Latitude and longitude: LAT    LON  MGRS   Grid       
    LAT/LON and MGRS default to the center of the grid square listed in Express Settings,  unless a GPS is used or LAT/LON  or MGRS must be entered
    manually.  Without properly formatted GPS coordinates this form cannot be mapped in Winlink Express.

     Attach CSV data file to message? Yes    No  

                                              
Ver 7.07