|Submit initial report ASAP after an incident and at least once per Operational Period or more frequently, as appropriate. |
|Date/Time: |
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|Facility Name: |
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|Initial Report or Update: |
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|Facility Liaison: |
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|Facility Situation Status (SitStat) |
|Operational Status |Check One |Evacuation |Yes |No |
|Partially Functional | |Have you evacuated any patients: | | |
|Not Functional | |Do you need help with evacuation? | | |
|Damage Assessment |Check One |# Sent to Hospital | |
|Total Collapse (requires closing) | |# Sent to SNF | |
|Partial Collapse | |# Sent to Shelter | |
|Some Structural Damage | |# Sent to Family/Caregiver | |
|No Structural Damage | | | |
|Utilities Functioning? |Yes |No |Clinical and Support Services |Functioning? |
|Medical Gases | | |Command Center Phone Number: | |
|Casualty Information |Number |Command Center Fax Number: | |
|# of patients prior to Incident. | |Provide a description of the impact to your facility due to the current event: |
|# of disaster related patients | |