Block
Number
Block Title Instructions
5 Hospitals
Enter the following information for hospital(s) that could serve this
incident:
• Hospital Name
Enter hospital name and identify any predesignated medivac aircraft by
name a frequency.
• Address, Latitude &
Longitude if Helipad
Enter the physical address of the hospital and the latitude and longitude
if the hospital has a helipad.
• Contact Number(s)/
Frequency
Enter the contact number(s) and/or communications frequency(s) for
the hospital.
• Travel Time
• Air
• Ground
Enter the travel time by air and ground from the incident to the hospital.
• Trauma Center
Yes Level:______
Indicate yes and the trauma level if the hospital has a trauma center.
• Burn Center
Yes No
Indicate (yes or no) if the hospital has a burn center.
• Helipad
Yes No
Indicate (yes or no) if the hospital has a helipad.
Latitude and Longitude data format need to compliment Medical
Evacuation Helicopters and Medical Air Resources
6 Special Medical Emergency
Procedures
Note any special emergency instructions for use by incident personnel,
including (1) who should be contacted, (2) how should they be
contacted; and (3) who manages an incident within an incident due to a
rescue, accident, etc. Include procedures for how to report medical
emergencies.
Check box if aviation assets
are utilized for rescue. If
assets are used, coordinate
with Air Operations.
Self explanatory. Incident assigned aviation assets should be included
in ICS 220.
7 Prepared by (Medical Unit
Leader)
• Name
• Signature
Enter the name and signature of the person preparing the form, typically
the Medical Unit Leader. Enter date (month/day/year) and time
prepared (24-hour clock).
8 Approved by (Safety Officer)
• Name
• Signature
•
Enter the name of the person who approved the plan, typically the
Safety Officer. Enter date (month/day/year) and time reviewed (24-hour
clock).
