HOSPITAL STATUS REPORT   (Short HICS 251)            
{var Title}  

{var IsExercise}

Report Type
{var aReportType}  {var updatenum}   
1. Incident Name {var Incident1} 2a. Date/Time: {var DateTime}
3a. Facility Name {var FacilityName3a} 3b. Facility Type: {var FacilType} : {var Othertype}
4a. Contact Name {var Contact4} 4b. Contact Phone {var Contactphone}    X    {var phoneX}
4c. Cell Phone {var Cell4} 4d. Contact Email Address {var Contactemail}

4e. Street Address: {var StreetADDRESS}      City: {var City}        State: {var State}        Zip Code: {var ZipCode}

Coordinates: Latitude: {var mapLat}  Longitude: {var mapLon}  MGRS : {var MGRS}    Grid Square: {var Grid}     Location source: {var locationSource}            
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)
 Ability to provide essential care services
{var A5a}
{var Comments5}
6. COMMUNICATIONS Impacted {var commipaired}
6a.  Email {var A6a}
6b.  Landline Phone {var A6b}
6c.  Fax {var A6c}
6d.  Internet {var A6d}
6e. Cell Phone {var A6e}
6f.  Satellite Phone {var A6f}
6g.  Amateur Radio {var A6g}
6h.{var Comments6}
7. UTILITIES    Impacted: {var utilitiesimpared}
7a. Power {var A7a}
7b. Water {var A7b}
7c. Sanitation {var A7c}
7d.Heating/Ventilation/AC {var A7d}
{var Comments7}
8. EVACUATIONS    {var evacConcerns}
8a. Evacuating?   {var Evac8} {var A8a}
8b. Partial Evacuation   {var Partial8} {var A8b}
8c. Total Evacuation   {var Total8} {var A8c}
8d. Shelter in place   {var Shelter8} {var A8d}
{var Comments8}  
9. CASUALTIES   {var thereArecausalties}
Immediate injuries = Critical care needed RED   Estimated # {var Immediate9}  
Delayed injuries = Moderate care needed YELLOW   Estimated # {var Delayed9}
Minor injuries = Care not needed immediately GREEN   Estimated # {var Minor9}
Fatalities BLACK = Deceased   Estimated # {var Fatalities9}
{var Comments9}
10. ADDITIONALI NFORMATION:
Internal disaster plan activated? {var plan10a} Facility Command Center activated? {var FCCActive10}
Emergency generator power in use? {var generator10} Will you send Resource Request within 4 hours? {var ResourceRreq10}
{var Comments10}

Version 2.3