HICS 206 - STAFF MEDICAL PLAN |
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1. INCIDENT NAME
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2. DATE PREPARED
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3. TIME PREPARED
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4. OPERATIONAL PERIOD DATE/TIME
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5. TREATMENT OF INJURED / STAFF |
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Location of Staff Treatment Area
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Contact Information
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Treatment Area Team Leader
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Contact Information
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Special Instructions
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6. RESOURCES ON HAND |
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STAFF |
MEDICAL TRANSPORTATION |
MEDICATION |
SUPPLIES |
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MD/DO: :10: |
Litters: :11: |
:12: |
:13: |
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PA/NP: :14: |
Portable :15: |
:16: |
:17: |
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RN/LPN: :18: |
Transport: :19: |
:20: |
:21: |
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Technicians/CN: :22: |
Wheelchairs: :23: |
:24: |
:25: |
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Ancillary/Other: :26: |
Trans'-Others: :27: |
:28: |
:29: |
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7. ALTERNATE CARE SITE(S) |
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NAME |
ADDRESS |
PHONE |
SPECIALTY CARE |
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:30: |
:31: |
:32: |
:33: |
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:34: |
:35: |
:36: |
:37: |
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:38: |
:39: |
:40: |
:41: |
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:42: |
:43: |
:44: |
:45: |
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8. PREPARED BY (SUPPORT BRANCH DIRECTOR): :46: |
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9. FACILITY NAME :47: |