Hospital Status Report

For generic use as desired.

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You can click on the Setup button top left of the template to add your group or agency name. This will remain as such until you change it.

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HOSPITAL STATUS REPORT

 Click to add your agency or group
    
  Form Info       


This is a radio delivery form for Express to Express users. However the information is in plain text in the message body and easily read by those that do not have the HTML template to view, such as a normal Internet email address.

 Report Time:    Report Date:     Event Occurrence Date/Time:  
 Do You Need Assistance?    Exercise?           

 Hospital:     Address:    
 

 Event Name:     County:  

 Person Submitting Report:      Phone(s):      

  Submitting Persons Email:   

  Briefly Describe Emergency as it Relates to Your Facility - Include any Expected Needs or Challenges? 

 
     
 Hospital Command Center Activated?         Level of Activation:   
 Current Conditions:        Conditions Expected to: 
 Are You on Generator Power?     Estimated Hours of Fuel?  
 Evacuating Now or Will Evacuate in Next 12 Hours?    Structural Damage or Imminent Danger? 

Detailed Facility Report
Complete the following best you can - Do not delay on reporting - If information is unknown indicate so
 Emergency Department
 
ICU
 
Operating
  
  Ambulance Access
  
  Nursery/NICU
 
Medical/Surgical  
     
Diagnostic Imaging
  
Labs
  
Pharmacy
 
Dialysis
 
Admin/Business
  
Behavorial Health
  
Respitory Therapy
 
Medical Practices
   
Physical Therapy
  
Morgue
  

HVAC
  
Heliport
  
Water
  
 Parking/Access
  
Linens
  
Medical Supplies
  
General Supplies
  
Sewage
  
Generators/Fuel
  
Medical Gases
  
Communications
  
Info Tech (IT)
  
Housekeeping
  
Electrical
  
Structural
  
Receiving
  
Facilities Management
  
Staffing
  
Medical Records
  
Food Services
  

  

  

  

  

   Briefly Explain any DEGRADED, *DISABLED*, or !DESTROYED!  Functions
 
                                                                                                                                                                 Vers 9.1