SAN DIEGO HOSPITAL STATUS REPORT FORM - Essential Elements
San Diego County Health Care Disaster Coalition

Send this form to San Diego County EMS DOC via WebEOC; or fax to Public Health Preparedness & Response Branch (PHPR) at 619-285-6531; or phone at 619-285-6433;
or via ARES-ACS or messenger.

BLOCK 0     {var BLOCK0}

[0A]  Operational Period    Date From {var sd0A}     

Date To    {var sd0B} 

Time From {var sd0C}

Time To     {var sd0D}

BLOCK 1 FACILITY ID
[1A]   Facility Name {var sd1A} [1B]  Facility City or Neighborhood {var sd1B}
[1C]   Facility Street Address {var sd1C}    
[1D]   IC Name {var sd1D} [1E]  IC Phone {var sd1E}
[1F]   Other Contact Name {var sd1F} [1G]  Other Contact Phone {var sd1G}
[1H-L]   Communications       {var sd1HWwebeoc}   {var sd1HRadio}   {var sd1HARES}   {var sd1HOther}
[1M]   Remarks
{var sd1I}
BLOCK 2 - CURRENT OPERATIONAL STATUS ( Select One ) BLOCK 3 NEXT OPERATIONAL PERIOD ( Select One )
[2A] Current Operational Status {var sd2A} [3A] Next Operational Period {var sd3A}
[2B] Remarks {var sd2B}
BLOCK 4 - DAMAGE ASSESSMENT (NO or YES) BLOCK 5 SERVICES- (YES or NO)
[4A] Damage Assessment {var sd4A} [5A] All services are available {var sd5A}
[4B] Evacuating hospital {var sd4B} [5B] Emergency Department functioning {var sd5B}
[4C] Internal disaster {var sd4C} [5C] Laboratory functioning {var sd5C}
[4D] Flooding {var sd4D} [5D] Operation Rooms functioning {var sd5D}
    [5E] Pharmacy functioning {var sd5E}
    [5F] Radiology functioning {var sd5F}
    [5G] Nutrition/Environmental functioning {var sd5G}
[4E] Remarks
{var sd4E}
[5H] Behavioral Health Unit functioning {var sd5H}
[5I] Morgue/Mass Fatality Area {var sd5I}
[5J] Remarks
{var sd5J}
BLOCK 6 UTILITY STATUS (YES or NO) BLOCK 7 SUPPLY LEVELS ADEQUATE
[6A] All utilities normal {var sd6A} [7A] Food / Water {var sd7A}
[6B] Elevator {var sd6B} [7B] Linen / Laundry {var sd7B}
[6C] HVAC {var sd6C} [7C] Medical / Surgical Supplies {var sd7C}
[6D] Information services (IT) {var sd6D} [7D] Pharmaceuticals {var sd7D}
[6E] Natural gas {var sd6E} [7E] Staffing {var sd7E}
[6F] Phone {var sd6F} [7F] Remarks and Supplies Needed
{var sd7F}
[6G] Water {var sd6G}
[6H] Waste water/sewer {var sd6H}
[6I] Electrical {var sd6I} BLOCK 8 HOW LONG WITHOUT ASSISTANCE
[6J] Electrical generator tested {var sd6J} [8A] How Long Without Assistance: {var sd8A}
[6k] Gen fuel status {var sd6K} [8B] Remarks
{var sd8B}
[6L] Remarks
{var sd6L}
BLOCK 9 - DAMAGE ASSESSMENT BLOCK 10 SURGE                                     COUNT
Evacuation ("TRAIN" Categories) TOTAL COUNT [10A] Casualty Information (in last 12 hours) {var sd10A}
[9A] Ambulatory to Evacuate (blue) {var sd9A} [10B] Patients Not Yet Seen {var sd10B}
[9B] Basic Life Support (BLS) to Evacuate (green) {var sd9B} [10C] Patients Treated and Released {var sd10C}
[9C] Advanced Life Support (ALS) to Evacuate (yellow) {var sd9C} [10D] Patients Admitted (in last 12 hours) {var sd10D}
[9D] Critical Care Transport (CCT) (orange) {var sd9D} [10E] Remarks
{var sd10E}
[9E] Specialized (red) {var sd9E}
[9F] Remarks
{var sd9F}
BLOCK 11 OTHER REMARKS {var sd11REMARKS}
 
BLOCK 12        {VAR EventType}