HICS 206 - STAFF MEDICAL PLAN

1. INCIDENT NAME

2. DATE PREPARED

3. TIME PREPARED

4. OPERATIONAL PERIOD DATE/TIME

5. TREATMENT OF INJURED / STAFF

Location of Staff Treatment Area

Contact Information

Treatment Area Team Leader

Contact Information

Special Instructions

6. RESOURCES ON HAND

STAFF

MEDICAL TRANSPORTATION

MEDICATION

SUPPLIES

MD/DO:

Litters:

PA/NP:

Portable

RN/LPN:

Transport:

Technicians/CN:

Wheelchairs:

Ancillary/Other:

Transport/Others:

7. ALTERNATE CARE SITE(S)

NAME

ADDRESS

PHONE

SPECIALTY CARE





8. PREPARED BY (SUPPORT BRANCH DIRECTOR):

9. FACILITY NAME