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, HEART 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? |