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1. Incident Name:
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2. Operational Period:
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From:
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To:
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Time:
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Time:
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3. Medical Aid Stations:
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Name
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Location
|
Contact Number(s)/Frequency
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Paramedics
on Site?
|
|
|
|
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Yes No
|
|
|
|
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Yes
No
|
|
|
|
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Yes
No
|
|
|
|
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Yes
No
|
|
|
|
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Yes
No
|
|
|
|
|
Yes
No
|
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4. Transportation (indicate
air or ground):
|
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Ambulance Service
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Location
|
Contact Number(s)/Frequency
|
Level of Service
|
|
|
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ALS BLS
|
|
|
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ALS BLS
|
|
|
|
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ALS BLS
|
|
|
|
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ALS BLS
|
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5. Hospitals:
|
|
Hospital Name
|
Address,
Latitude & Longitude
if Helipad
|
Contact Number(s)/ Frequency
|
Travel Time
|
Trauma Center
|
Burn Center
|
Helipad
|
|
Air
|
Ground
|
|
|
|
|
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Yes
Level:
|
Yes
No
|
Yes No
|
|
|
|
|
|
Yes
Level:
|
Yes No
|
Yes
No
|
|
|
|
|
|
|
Yes
Level:
|
Yes No
|
Yes No
|
|
|
|
|
|
|
Yes
Level:
|
Yes No
|
Yes
No
|
|
|
|
|
|
|
Yes
Level:
|
Yes
No
|
Yes
No
|
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6. Special Medical Emergency
Procedures:
|
|
|
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Check box if aviation assets are utilized
for rescue. If assets are used, coordinate with Air
Operations.
|
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7. Prepared by
(Medical Unit Leader):
|
Name:
|
Signature:
|
|
8. Approved by
(Safety Officer):
|
Name:
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Signature:
|
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ICS 206
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IAP Page
|
Date/Time:
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