Laundry/Linen Service Equipment Fully functional  Partially functional  Nonfunctional  N/A  Structural Components Fully functional (Note cracked walls, loose masonry, hanging light fixtures, broken windows)  Building integrity Partially functional  Nonfunctional  N/A  PATIENT CARE Decontamination System Fully functional  Including containment Partially functional  Nonfunctional  N/A  Digital Radiography System, Routine Fully functional  Diagnostics Partially functional  PACS, CT, MRI, other Nonfunctional  N/A  Steam/Chemical Sterilizers Fully functional  Partially functional  Nonfunctional  N/A  Isolation Rooms Fully functional  Positive/negative air Partially functional  Nonfunctional  N/A  SECURITY Facility Lockdown Systems Fully functional  Door/key card access Partially functional  Nonfunctional  N/A  Campus Security Fully functional  External panic alarms Partially functional  Nonfunctional  N/A  Campus Security Fully functional  Surveillance cameras Partially functional  Nonfunctional  N/A  Campus Security Fully functional  Traffic controls Partially functional  Nonfunctional  N/A  Purpose: Determine facility operating status Origination: Infrastructure Branch Director Copies to: Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, Safety Officer, Liaison Officer, Materiel Tracking Managers, and the Documentation Unit Leader HICS 251 | Page 3 of 6
Laundry/Linen Service Equipment  Fully functional  Partially functional  Nonfunctional  N/A Structural Components Building integrity  Fully functional  Partially functional  Nonfunctional  N/A (Note cracked walls, loose masonry, hanging light fixtures, broken windows) PATIENT CARE Decontamination System Including containment  Fully functional  Partially functional  Nonfunctional  N/A Digital Radiography System, Routine Diagnostics PACS, CT, MRI, other  Fully functional  Partially functional  Nonfunctional  N/A Steam/Chemical Sterilizers  Fully functional  Partially functional  Nonfunctional  N/A Isolation Rooms Positive/negative air  Fully functional  Partially functional  Nonfunctional  N/A SECURITY Facility Lockdown Systems Door/key card access  Fully functional  Partially functional  Nonfunctional  N/A Campus Security External panic alarms  Fully functional  Partially functional  Nonfunctional  N/A Campus Security Surveillance cameras  Fully functional  Partially functional  Nonfunctional  N/A Campus Security Traffic controls  Fully functional  Partially functional  Nonfunctional  N/A Purpose: Determine facility operating status Origination: Infrastructure Branch Director Copies to: Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, Safety Officer, Liaison Officer, Materiel Tracking Managers, and the Documentation Unit Leader HICS 251 | Page 3 of 6
HICS-2014-Forms.docx