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
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