Emergency Preparedness

Appendix S.1 Damage Assessment Form Kern Medical Center Initial Response Information Sheet For Disaster - Code Triage This form must be completed within 5 minutes after code is called Date: ___________________ Time: ____________________ Department Reporting: _______________ Unit Leader:____________________ STAFF: TOTAL # of staff in unit: ____________ Breakdown: RN Physicians Ancillary Staff LVN Visitors on UNIT: ________________ BEDS: Occupied: _______________ Available: _____________ Ambulatory Patients: _____________________ NON-Ambulatory Patients: __________________ C.N.A Clerical Support Services Other B ____ Limited ability due to staff injuries or damage to unit or equipment C ____ Unable to provide any service - area is unsafe or unable to staff PLEASE NOTE: If you have checked box B or C above, give explanation below. ________________________________________________________________________ ________________________________________________________________________ How many staff are available for use in the labor pool? Licensed _______ Non-licensed _________ Person Completing Form: _______________________________ Ext or Cell #: _____________ (Please print clearly) Distribution: Please Fax to 326-2953 and place original at designated unit area If unable to fax, a runner will be by to collect the form. Please have it ready. Phones Working? ____ Yes ____ No Normal Power? ____ Yes ____ No Normal Water? ____ Yes ____ No Service Capacity: A ____ Normal business as usual

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