This is a generic Bed Report Form.

It is for reporting available beds at a facility.
You enter your Jurisdiction, Group, or entity name at the top right.
Example: Basset County RACES or San Bernardino County Health. This form will total the available bed counts for you.

Based on W2SRP original Marion County Florida form.


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This form can be customized with a name by using the "Setup" button on the top right. This entry will stay with the form until you change it.

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  DEPARTMENT OF HEALTH SERVICES
  COUNTY OF LOS ANGELES
           


  SUBJECT: BED AVAILABILITY REPORT
(HOSPITALS)  
REFERENCE NO. 1122.1
  

{var IsExercise}

Hospital Name: {var Hospital}

  Hospital Service Level: {var ServiceLevel}  Time of HSL: {var Timehsl} 
BED AVAILABILITY
# Available
Immediately
1
Medical/Surgical
{var A1}
2
Telemetry
{var B1}
3
Adult ICU
{var C1}
4
Pediatric ICU
{var D1}
5
Neonatal ICU
{var E1}
6
Pediatric Bed
{var F1}
7
Obstetrics/Gynecology
{var G1}
8
Trauma
{var H1}
9
Burn
{var I1}
10
Negative Pressure/Isolation
{var J1}
11
Psychiatric
{var K1}
12
Operating Room
{var L1}
13
{var otherservicea}
{var O1}
14
Ventilator
{var N1}
15
Mass Decontamination Facility Available
{var MassDecon}

Report Completed by: {var Name} 
 
Phone Number: {var Phone}
 
Date /Time: {var DateTime}

  Addtional Comments:
{var Comments}

FAX COMPLETED FORM TO THE MEDICAL ALERT CENTER
AT (562) 906-4300
OR
SEND TO LAC-MAC VIA WINLINK
WITHIN 60 MINUTES OF REQUEST

EFFECTIVE: 03-19-09
REVISED: 04-01-23
SUPERSEDES: 10-01-20
 
PAGE 1 OF 1  
 Express Sending Station: {MsgSender}
Version 1.8.0  

 
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