Emergency Preparedness

Appendix O.16 HICS 259 HOSPITAL CASUALTY/FATALITY REPORT

1. Incident Name

2. Operational Period (# ) DATE: FROM: ________________________________________________ TO: ______________________________________________

TIME: FROM: ________________________________________________ TO: ______________________________________________

3. Number of Casualties / Fatalities

ADULT

PEDIATRIC (<18 YRS OLD)

TOTAL

COMMENTS

• Patients seen

• Admitted

• Critical Care

Medical / Surgical

Other

Other

Other

Discharged

Transferred

Morgue

Waiting to be seen

4. Prepared by

PRINT NAME:

_________________________________________________________________________

SIGNATURE:

_______________________________________________________________________

DATE/TIME:

__________________________________________________________________________

FACILITY: __________________________________________________________________________