Emergency Preparedness

Appendix O.8 HICS 251 FACILITY SYSTEM STATUS REPORT

2. Time Completed: (# ) DATE:

1. Incident Name

FROM: ___________________________________ TO: __________________________________ TIME: FROM: ___________________________________ TO: __________________________________

3. Name of Department / Unit Reporting Status Below

Contact Number:

6. Comments If not fully functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.

4. System

5. Status

Power Routine and emergency

 Fully functional  Partially functional  Nonfunctional  N/A  Fully functional  Partially functional  Nonfunctional  N/A  Fully functional  Partially functional  Nonfunctional  N/A  Fully functional  Partially functional  Nonfunctional  N/A  Fully functional  Partially functional  Nonfunctional  N/A  Fully functional  Partially functional  Nonfunctional  N/A  Fully functional  Partially functional  Nonfunctional  N/A

Lighting

Water

Sewage / Toilets

Nurse Call System

Medical Gases / Oxygen

Communications IT systems, telephones, pagers

7. Remarks (Cracked walls, broken glass, falling light fixtures, etc.)

8. Prepared by

PRINT NAME: ______________________________________________________

____________________________________________________________

SIGNATURE:

________________________________________________________

FACILITY: _______________________________________________________________

DATE/TIME:

2. Operational Period (# )

1. Incident Name

Patient Decontamination Recommendations for Hospitals v July 2005 367