HICS-213 - INCIDENT MESSAGE FORM

1. FROM (Sender):

2. TO (Receiver):

3. DATE RECEIVED:

4. TIME RECEIVED:

5. RECEIVED VIA

Phone
Radio
Other

6. REPLY REQUESTED:

Yes No

If YES, REPLY TO:

7. PRIORITY

Urgent - High Non Urgent – Medium Informational - Low

8. MESSAGE (KEEP ALL MESSAGES / REQUESTS BRIEF, TO THE POINT, AND VERY SPECIFIC):

9. ACTION TAKEN (if any):


Receipt 1

Received by:

Time Received:

Forward to:

Comments:


Receipt 2

Received by:

Time Received:

Forward to:

Comments:

10. FACILITY NAME