{var Title} HOSPITAL STATUS REPORT

  Report Time:    Report Date:     Event Occurrence Date/Time:  

  Assistance Needed?
     Exercise?                  Express Sender  

  Hospital:    Address:  
 

  Event Name:    County:  

  Person Submitting Report:     Phone(s):  

  Submiiting Persons Email:    
 
Comments on the Emergency as it Relates to This Facility - Includes any Expected Needs or Challenges

 {var Report}
      Hospital Command Center Activated?          Level of Activation:       
 

Current Conditons:         Conditons Expected to:  

Facility on Generator Power?         Estimated Hours of Fuel?  

Evacuating Now or Will Evacuate in Next 12 Hours?  
   Structural Damage or Imminent Danger?  

Detailed Facility Report
 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



 

 

 

   Comments concerning any DEGRADED, *DISABLED*, or !DESTROYED! Functions 

{var Comments}

 
version {var version}