HICS 255 - MASTER PATIENT EVACUATION TRACKING 1. Incident Name 2. Operational Period (# ) DATE: FROM: TO: TIME: FROM: TO: 3. Patient Evacuation Information Evacuation Triage Category Mode of Transport Medical Record # PATIENT NAME CCT ALS BLS VAN     IMMEDIATE DELAYED MINOR    BUS CAR AIRCRAFT    Disposition Accepting Hospital or Location Time hospital contacted & report given DISCHARGE  TRANSFER  MORGUE  Transfer Initiated (Time/Transport Co./ #) Medical Record Sent Medication Sent Family Notified Arrival Confirmed Admit Location Expired (time) FLOOR ICU   YES NO YES NO YES NO YES NO         ER MORGUE   Evacuation Triage Category Mode of Transport Medical Record # PATIENT NAME CCT ALS BLS VAN     IMMEDIATE DELAYED MINOR    BUS CAR AIRCRAFT    Disposition Accepting Hospital or Location Time hospital contacted & report given DISCHARGE  TRANSFER  MORGUE  Transfer Initiated (Time/Transport Co./ #) Medical Record Sent Medication Sent Family Notified Arrival Confirmed Admit Location (time) Expired FLOOR ICU   YES NO YES NO YES NO YES NO         ER MORGUE   Medical Record # Evacuation Triage Category Mode of Transport PATIENT NAME CCT ALS BLS VAN     IMMEDIATE DELAYED MINOR    BUS CAR AIRCRAFT    Disposition Time hospital contacted & report given Accepting Hospital or Location DISCHARGE  TRANSFER  MORGUE  Transfer Initiated (Time/Transport Co./ #) Medical Record Sent Medication Sent Family Notified Arrival Confirmed Admit Location Expired (time) FLOOR ICU   YES NO YES NO YES NO YES NO         ER MORGUE   Medical Record # Evacuation Triage Category Mode of Transport PATIENT NAME CCT ALS BLS VAN     IMMEDIATE DELAYED MINOR    BUS CAR AIRCRAFT    Disposition Time hospital contacted & report given Accepting Hospital or Location DISCHARGE  TRANSFER  MORGUE  Transfer Initiated (Time/Transport Co./ #) Medical Record Sent Medication Sent Family Notified Arrival Confirmed Admit Location Expired (time) FLOOR ICU   YES NO YES NO YES NO YES NO         ER MORGUE   4. Prepared by PRINT NAME: SIGNATURE: DATE/TIME: FACILITY:
HICS 255 - MASTER PATIENT EVACUATION TRACKING 1. Incident Name 2. Operational Period (# ) DATE: FROM: TO: TIME: FROM: TO: 3. Patient Evacuation Information PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) PATIENT NAME Medical Record # Evacuation Triage Category  IMMEDIATE  DELAYED  MINOR Mode of Transport  CCT  ALS  BLS  VAN  BUS  CAR  AIRCRAFT Disposition  DISCHARGE  TRANSFER  MORGUE Accepting Hospital or Location Time hospital contacted & report given Transfer Initiated (Time/Transport Co./ #) Medical Record Sent  YES  NO Medication Sent  YES  NO Family Notified  YES  NO Arrival Confirmed  YES  NO Admit Location  FLOOR  ICU  ER  MORGUE Expired (time) 4. Prepared by PRINT NAME: SIGNATURE: DATE/TIME: FACILITY:
HICS-Evac-Tracking-forms_2.docx