2. Operational Period (# ) 1. Incident Name DATE: FROM: _________ TO: TIME: FROM: _ TO: 3. Name of Facility / Building Reporting Status Below 6. Comments If not fully functional, give location, reason, and estimated 4. System 5. Status time/resources for necessary repair. Identify who reported or inspected. COM M UNICATIONS Fax Fully functional  Partially functional  Nonfunctional  N/A  Information Technology System Fully functional  Email, registration, patient records, Partially functional time card system  Nonfunctional  N/A  Nurse Call System Fully functional  Partially functional  Nonfunctional  N/A  Overhead Paging Fully functional  Partially functional  Nonfunctional  N/A  Paging System Fully functional  Code teams, standard paging Partially functional  Nonfunctional  N/A  Radio Equipment Fully functional  Facility handheld, 2-way radios, antennas Partially functional  Nonfunctional  N/A  Radio Equipment Fully functional  EMS, local health department, other external Partially functional  Partner Nonfunctional  N/A  Radio Equipment Fully functional  Amateur radio Partially functional  Nonfunctional  N/A  Satellite Phones 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, HICS 251 | Page 1 of 6 Safety Officer, Liaison Officer, Materiel Tracking Managers, and Documentation Unit Leader
1. Incident Name 2. Operational Period (# ) DATE: FROM: _________ TO: TIME: FROM: _ TO: 3. Name of Facility / Building Reporting Status Below 4. System 5. Status 6. Comments If not fully functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected. COM M UNICATIONS Fax  Fully functional  Partially functional  Nonfunctional  N/A Information Technology System Email, registration, patient records, time card system  Fully functional  Partially functional  Nonfunctional  N/A Nurse Call System  Fully functional  Partially functional  Nonfunctional  N/A Overhead Paging  Fully functional  Partially functional  Nonfunctional  N/A Paging System Code teams, standard paging  Fully functional  Partially functional  Nonfunctional  N/A Radio Equipment Facility handheld, 2-way radios, antennas  Fully functional  Partially functional  Nonfunctional  N/A Radio Equipment EMS, local health department, other external Partner  Fully functional  Partially functional  Nonfunctional  N/A Radio Equipment Amateur radio  Fully functional  Partially functional  Nonfunctional  N/A Satellite Phones  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 Documentation Unit Leader HICS 251 | Page 1 of 6
HICS-2014-Forms.docx