Attachment A HICS 254 - DISASTER VICTIM/PATIENT TRACKING FORM INCIDENT NAME DATE/TIME PREPARED 3. OPERATIONAL PERIOD DATE/TIME 4. TRIAGE AREAS (Immediate, Delayed, Expectant, Minor, Morgue) Location/Time of Disposition MR#/ Diagnostic Procedures Time sent to Time of (home, admit, morgue, Triage # Name Sex Area Triaged to (x-ray, angio, CT, etc.) Surgery Disposition transfer) 5. SUBMITTED BY 6. AREA ASSIGNED TO 7. DATE/TIME SUBMITTED 8. FACILITY NAME
Attachment A HICS 254 - DISASTER VICTIM/PATIENT TRACKING FORM INCIDENT NAME DATE/TIME PREPARED 3. OPERATIONAL PERIOD DATE/TIME 4. TRIAGE AREAS (Immediate, Delayed, Expectant, Minor, Morgue) MR#/ Triage # Name Sex Area Triaged to Location/Time of Diagnostic Procedures (x-ray, angio, CT, etc.) Time sent to Surgery Disposition (home, admit, morgue, transfer) Time of Disposition 5. SUBMITTED BY 6. AREA ASSIGNED TO 7. DATE/TIME SUBMITTED 8. FACILITY NAME
TN-CSC-7-27-2016.docx