1) Incident Name: 2) Operational Period: Date From: Date To: Time From: Time To: 3) Medical Aid Stations Contact Name Location Paramedics On Site? Number(s)/Frequency Yes No Yes No Yes No Yes No Yes No 4) Transportation (indicate Air or Ground) Contact Ambulance Services Location Level of Service Number(s)/Frequency ALS BLS ALS BLS ALS BLS ALS BLS 5) Hospitals Address Travel Time Contact Trauma Burn Hospital Name (Latitude & Longitude Helipad Number(s)/Frequency Air Ground Center Center if Helipad) Yes Yes Yes No No Level: Yes Yes Yes No No Level: Yes Yes Yes No No Level: Yes Yes Yes No No Level: 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) Name: Position/Title: Signature: Date/Time: 8) Approved By: (Safety Officer) Name: Position/Title: Signature: Date/Time: ICS 206 IAP Page:
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 4) Transportation (indicate Air or Ground) Ambulance Services 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 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) Name: Position/Title: Signature: Date/Time: 8) Approved By: (Safety Officer) Name: Position/Title: Signature: Date/Time: ICS 206 IAP Page:
ICS-206.docx