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