Emergency Preparedness

Appendix H.26 – TRANSPORT LOG FORM

Kern Medical Emergency Preparedness

Form B: Transportation Log for Evacuated Patients

Transport Vehicle #____

Name of Transport Company Number or License Number of Transport Vehicle Patient #1 Name:

Triage Tag Number: Triage Tag Number: Triage Tag Number: Triage Tag Number:

Patient #2 Name: Patient #3 Name: Patient #4 Name:

Name of staff person, accompanying patient Destination Site Name of Transport Company Number or License Number of Transport Vehicle Patient #1 Name: Name of staff person, accompanying patient Destination Site Name of Transport Company Number or License Number of Transport Vehicle Patient #1 Name: Name of staff person, accompanying patient Destination Site Name of Transport Company Number or License Number of Transport Vehicle Patient #1 Name: Patient #2 Name: Patient #3 Name: Patient #4 Name: Patient #2 Name: Patient #3 Name: Patient #4 Name:

Transport Vehicle #____

Triage Tag Number: Triage Tag Number: Triage Tag Number: Triage Tag Number:

Transport Vehicle #____

Triage Tag Number: Triage Tag Number: Triage Tag Number: Triage Tag Number:

Transport Vehicle #____

Triage Tag Number: Triage Tag Number: Triage Tag Number: Triage Tag Number:

Patient #2 Name: Patient #3 Name: Patient #4 Name:

Name of staff person, accompanying patient Destination Site

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