Form: SDG_ARES_Hospital_Status_Initial.html,SDG_ARES_Hospital_Status_Viewer.html
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Subject:SDG Hospital Status--
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BLOCK 0 --->
[0A] Operational Period
Date From: Date To:
Time From: Time To:
BLOCK 1 FACILITY ID
1A Facility Name:
1B Facility City or Neighborhood:
1C Facility Street Address:
1D IC Name:
1E IC Phone:
1F Other Contact Name:
1G Other Contact Phone:
1H Communications:
1K Remarks:
BLOCK 2 CURRENT OPERATIONAL STATUS
2A Current Operational Status:
2B Remarks:
BLOCK 3 NEXT OPERATIONAL PERIOD
3A Next Operational Period:
BLOCK 4 DAMAGE ASSESSMENT
4A Damage Assessment:
4B Evacuating Hospital:
4C Internal Disaster:
4D Flooding:
4E Remarks:
BLOCK 5 SERVICES (YES or NO)
5A All Services Are Available:
5B Emergency Department Functioning:
5C Laboratory Functioning:
5D Operation Rooms Functioning:
5E Pharmacy Functioning:
5F Radiology Functioning:
5G Nutrition/Environmental Functioning:
5H Behavioral Health Unit Functioning:
5I Remarks:
BLOCK 6 UTILITY STATUS (YES or NO)
6A All Utilities Normal:
6B Elevator:
6C HVAC:
6D Information Services (IT):
6E Natural Gas:
6F Phone:
6G Water:
6H Waste Water/Sewer:
6I Electrical:
6J Electrical Generator Tested:
6K Gen Fuel Status:
6M Remarks:
BLOCK 7 CRITICAL NEEDS
7A Food/Water:
7B Linen/Laundry:
7C Medical/Surgical Supplies:
7D Pharmaceuticals:
7E Staffing:
7F Remarks and Supplies Needed:
BLOCK 8 HOW LONG WITHOUT ASSISTANCE
8A How Long Without Assistance:
8B Remarks:
BLOCK 9 EVACUATION
Evacuation ("TRAIN" Categories) TOTAL COUNT:
9A Ambulatory to Evacuate (BLUE):
9B Basic Life Support (BLS) to Evacuate (GREEN):
9C Advanced Life Support (ALS) to Evacuate (YELLOW):
9D Critical Care Transport (CCT) (ORANGE):
9E Specialized (RED):
9F Remarks:
BLOCK 10 SURGE COUNT
10A Casualty Information (in last 12 hours):
10B Patients Not Yet Seen:
10C Patients Treated and Released:
10D Patients Admitted (in last 12 hours):
10E Remarks:
BLOCK 11 OTHER REMARKS:
BLOCK 12 EVENT TYPE ---> []
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