SITUATION REPORT (Short HICS251)
NUMBER
TITLE
INSTRUCTIONS
1
Incident Name
Enter the name assigned to the incident.
2a & 2b
Operational Period
Enter the start date (m/d/y) and time (12 hour clock) and end date and time.
3a & 3b
Facility Name &
Type
Enter the name of the facility and type
4a , 4b,
4c & 4d
Contact Info
Contact name, phone, cell phone and email
5
Status
Normal
: 100% operable with no limitations
Modified
: Operable or somewhat operable with limitations
Limited
: Partial functional some assistance needed
Impaired
: Major assistance needed
Not functional
: Major assistance needed
Unknown
: Not applicable, do not have info
6
Communications
Email, land line phone, fax, internet, cell phone, satellite phone, amateur radio
7
Utilities
Power, water, sanitation, heating, A/C, ventilation
8
Evacuation
Evacuating: Partial evacuation, Total evacuation, Shelter in Place.
9
Impact/Casualties
Immediate (Red):
Critical care
Delayed (Yellow)
: Moderate care
Minor (Green)
: Care not needed immediately
Fatality (Black)
: Deceased
10
Additional Information
Internal disaster plan activated?
Facility Command Center activated?
Emergency generator power in use?
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HOSPITAL STATUS REPORT
(Short HICS 251)
Click to add your agency or group name to title
Form Info
Report Type (check one)
Initial
Update #
Final
1. Incident Name
2. Date/time:
3a. Facility Name
3b. Facility Type
Hospital
Clinic
LTCF
Other, specify:
Latitude
Longitude
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 are entered manually.
For accurate mapping you must enter the latitude and longitude.
4a. Contact Name
4b. Contact Phone
X
4c. Cell Phone
4d. Contact Email Address
5. FACILITY OPERATING STATUS
Normal
Modified
- partially functional - no assistance needed (explain)
Limited-
partially functional,- Some assistance needed (explain)
UNKNOWN
Impaired-
major assistance needed (explain)
Not functional-
major assistance needed (explain)
Check ability to provide essential care services
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6. COMMUNICATIONS Impacted:
YES
NO
6a. Email
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6b. Landline Phone
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6c. Fax
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6d. Internet
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6e. Cell Phone
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6f. Satellite Phone
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
6g. Amateur Radio
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
7. UTILITIES Impacted:
YES
NO
7a. Power
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
7b. Water
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
7c. Sanitation
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
7d. Heating/Ventilation/AC
NORMAL
MODIFIED
LIMITED
IMPAIRED
NOT FUNCTIONAL
UNKNOWN
8. EVACUATIONS
YES
NO
8a. Evacuating?
YES
NO
IF Yes, it is:
Anticipated
In progress
Completed
8b. Partial Evacuation
YES
NO
IF Yes, it is:
Anticipated
In progress
Completed
8c. Total Evacuation
YES
NO
IF Yes, it is:
Anticipated
In progress
Completed
8d. Shelter in place
YES
NO
IF Yes, it is:
Anticipated
In progress
Completed
9. CASUALTIES
YES
NO
Immediate injuries = Critical care needed
RED
Estimated #
MapFileName:T=General Hospital Status DateTime:T=j2 Latitude:T=j4 Longitude:T=j5 MGRS:T=j6 Grid:T=j7 Report Type:T=aReportType Status:M:updatenum 01. Incident Name:M=Incident1 02a. Date/Time:T=Datetime 03. Facility Name: T=FacilityName3a 03b. Facility Type: T=FacilType 04a. Contact Name: T=Contact4 04b. Contact Phone:T=Contactphone 04c. Extension:T=phoneX 04d. Cell Phone: T=Cell4 04e. Contact Email Address: T=Contactemail 05. Facility Operating Status: M:NORMAL,MODIFIED,LIMITED,IMPAIRED,NOT FUNCTIONAL,UNKNOWN=A5a 06. COMMUNICATIONS Impacted:M:YES,NO=commipaired 07. Utilities Impacted:M:YES,NO=utilitiesimpared 08. EVACUATIONS:M:YES,NO=evacConcerns 09. CASULITIES:M:YES,NO=thereArecausalties 10. Internal disaster plan activated:M:YES,NO=plan10a 10a. Facility Command Center activated:M:YES,NO=FCCActive10 10b. Emergency generator power in use:M:YES,NO=generator10 10c. Resource Request within 4 hours:M:YES,NO=ResourceRreq10 10d. ADDITIONAL INFORMATION: T=Comments10
Delayed injuries = Moderate care needed
YELLOW
Estimated #
Minor injuries = Care not needed immediately
GREEN
Estimated #
Fatalities BLACK = Deceased
Estimated #
10. ADDITIONALINFORMATION:
Internal disaster plan activated?
YES
NO
Facility Command Center activated?
YES
NO
Emergency generator power in use?
YES
NO
Will you send Resource Request within 4 hours?
YES
NO
Comments
Version 2.1