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 #  
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

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