HICS 206 - STAFF MEDICAL PLAN

1. INCIDENT NAME
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2. DATE PREPARED
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3. TIME PREPARED
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4. OPERATIONAL PERIOD DATE/TIME
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5. TREATMENT OF INJURED / STAFF

Location of Staff Treatment Area
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Contact Information
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Treatment Area Team Leader
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Contact Information
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Special Instructions

:9:

6. RESOURCES ON HAND

STAFF

MEDICAL TRANSPORTATION

MEDICATION

SUPPLIES

MD/DO: :10:

Litters: :11:

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PA/NP: :14:

Portable :15:

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RN/LPN: :18:

Transport: :19:

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Technicians/CN: :22:

Wheelchairs: :23:

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Ancillary/Other: :26:

Trans'-Others: :27:

:28:

:29:

7. ALTERNATE CARE SITE(S)

NAME

ADDRESS

PHONE

SPECIALTY CARE

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:32:

:33:

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8. PREPARED BY (SUPPORT BRANCH DIRECTOR): :46:

9. FACILITY NAME :47: