5 Hospitals Enter the following information for hospital(s) that could serve this incident: Hospital Name Enter hospital name and identify any predesignated medivac aircraft by name a frequency. Address, Latitude & Enter the physical address of the hospital and the latitude and longitude Longitude if Helipad if the hospital has a helipad. Contact Number(s)/ Enter the contact number(s) and/or communications frequency(s) for Frequency the hospital. Travel Time Enter the travel time by air and ground from the incident to the hospital. Air Ground Indicate yes and the trauma level if the hospital has a trauma center. Trauma Center Yes Level:______ Indicate (yes or no) if the hospital has a burn center. Burn Center Yes No Indicate (yes or no) if the hospital has a helipad. Helipad Yes No Latitude and Longitude data format need to compliment Medical Evacuation Helicopters and Medical Air Resources Special Medical Emergency Note any special emergency instructions for use by incident personnel, 6 Procedures including (1) who should be contacted, (2) how should they be contacted; and (3) who manages an incident within an incident due to a rescue, accident, etc. Include procedures for how to report medical emergencies. Check box if aviation assets Self explanatory. Incident assigned aviation assets should be included are utilized for rescue. If in ICS 220. assets are used, coordinate with Air Operations. (Medical Unit Enter the name and signature of the person preparing the form, typically 7 Prepared by Leader) the Medical Unit Leader. Enter date (month/day/year) and time prepared (24-hour clock). Name Signature (Safety Officer) Enter the name of the person who approved the plan, typically the 8 Approved by Safety Officer. Enter date (month/day/year) and time reviewed (24-hour Name clock). Signature Date/Time
5 Hospitals Enter the following information for hospital(s) that could serve this incident: Hospital Name Enter hospital name and identify any predesignated medivac aircraft by name a frequency. Address, Latitude & Longitude if Helipad Enter the physical address of the hospital and the latitude and longitude if the hospital has a helipad. Contact Number(s)/ Frequency Enter the contact number(s) and/or communications frequency(s) for the hospital. Travel Time Air Ground Enter the travel time by air and ground from the incident to the hospital. Trauma Center Yes Level:______ Indicate yes and the trauma level if the hospital has a trauma center. Burn Center Yes No Indicate (yes or no) if the hospital has a burn center. Helipad Yes No Indicate (yes or no) if the hospital has a helipad. Latitude and Longitude data format need to compliment Medical Evacuation Helicopters and Medical Air Resources 6 Special Medical Emergency Procedures Note any special emergency instructions for use by incident personnel, including (1) who should be contacted, (2) how should they be contacted; and (3) who manages an incident within an incident due to a rescue, accident, etc. Include procedures for how to report medical emergencies. Check box if aviation assets are utilized for rescue. If assets are used, coordinate with Air Operations. Self explanatory. Incident assigned aviation assets should be included in ICS 220. 7 Prepared by (Medical Unit Leader) Name Signature Enter the name and signature of the person preparing the form, typically the Medical Unit Leader. Enter date (month/day/year) and time prepared (24-hour clock). 8 Approved by (Safety Officer) Name Signature Date/Time Enter the name of the person who approved the plan, typically the Safety Officer. Enter date (month/day/year) and time reviewed (24-hour clock).