{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}