California Standardized Emergency Management System
                         Event/Major Incident Report

Operational Area:  

From City:     

Region:                       

Law Mutual Aid Region:                 Fire Mutual Aid Region:  

1. a. Overall Event Name: (If this is an incident related to a larger event,
                          select the name of the larger event.  Otherwise, 
                          name this event/incident.)            

b. Disaster Number:	

2. Incident Name: (If this is an incident related to a larger event, name 
                  this incident.  Otherwise, leave blank.) 

3. Event/Incident Type: 	

4. Date/Time of Event/Incident: 

5. Event/Incident Location

a. Descriptive: 

b. Street: 

   Number   Direction     Street                  Suffix 
            (N, S, E, W)                          (Rd, St, Ave, etc) 	
			
   Cross Street (if available)			

c. City:                               d. Zip: 

e. Map Reference: (Identify Map)
 
f. Latitude:   Longitude:   Thomas Bros. Page:   Grid:   

6. Event/Incident Impact: (Major/Moderate/Minor/Routine) 

7. Situation: 

Functional Area Impact	(Optional)   |Remarks  (Optional)
------------------------------------------------------------------------------
8.  Fire and Rescue:   |(Red/Black/  |		
                       |Yellow/Green)|
                       |             |
9. Law Enforcement:    |(Red/Black/  |		
                       |Yellow/Green)|
                       |             |
10.  Care and Shelter: |(Red/Black/  |		
                       |Yellow/Green)|
                       |             | 
11.  Medical/Health:   |(Red/Black/  |		
                       |Yellow/Green)|
                       |             |
12.  Movement:         |(Red/Black/  |		
                       |Yellow/Green)|
                       |             |
13.  Constr and Engr:  |(Red/Black/  |		
                       |Yellow/Green)|
                       |             |
14.  Utility:          |(Red/Black/  |		
                       |Yellow/Green)|
                       |             | 
15.  EOC Activated?    |(Yes/No/Unk) |
                       |             |
16. Mutual Aid Received|(Yes/No/Unk) |
    in Last 24 Hours?  |             |
                       |             |
17. Mutual Aid Needed  |(Yes/No/Unk) |
    in Next 24 Hours?  |             |
                       |             |
18. Critical Issues?   |             | 

19.  Prognosis: (No Change/Worsening/Improving) 		

20.  Reported by

20a. Name:                             20b Agency: 

20c. Phone:                            20d. Fax Number:  

20e. Alt Phone:  

21. Date/Time of this Report:  (date/time)

22. Person Receiving Report

22a. Name:                             22b Agency: 

22c. Phone:                            22d. Fax Number:  

22e. Alt Phone:  

23. Additional rich text information:  



Created by: Bill Pennington        on: (date/time)   

Last Modified by:                  on: (date/time)