California Standardized Emergency Management System
                        Medical/Health Branch Status Report

From County Operational Area:     

Region:                       

Law Mutual Aid Region:  	       Fire Mutual Aid Region:  

1. Event Name:                         2. Event Date: 

3. Overall Status: (Red/Black/Yellow   4. As Of: (date/time)
                   Green)

5. Areas Affected: 

6. Situation: 

EMS                          |a. Status   |b. Remarks
------------------------------------------------------------------------------
7. Estimated Casualties      |            |		
                             |            |
a. Deaths:                   |            |
                             |            |
b. Major Injuries:           |            |
                             |            |
c. Minor Injuries:           |            |
                             |            | 
d. Missing:                  |            |
                             |            |
8. Hospital Status           |            |
                             |            |
a. Total acute care:         |            |
                             |            | 
b. # not functioning:        |            |
                             |            |
c. # partially functional:   |            |	 	
                             |            |
d. # fully functional:       |            |
                             |            |
e. # not reporting:          |            |
                             |            |
9. Status of nursing homes,  |(Red/Black/ |
   clinics & field treatment |Ywllow/Green|
   sites:                    |            |
                             |            |
10. Mutual Aid Needs         |            |
                             |            |
a. Medical personnel?        |  (Yes/No)  |
                             |            |
b. Medical supplies?         |  (Yes/No)  |
                             |            |
c. Med. Transportation?      |  (Yes/No)  |
  

PUBLIC/ENVIR HEALTH          |a. Status   |b. Remarks		
------------------------------------------------------------------------------
11. Personnel Needed?        |            |
                             |            |
12. Public Water Systems     |            |
                             |            |
a. Damaged?                  |(Yes/No/Unk)|
                             |            |
b. Contaminated?             |(Yes/No/Unk)|
                             |            |
c. Number affected:          |            |
                             |            |
13. Sewage/Solid Waste       |(Yes/No/Unk)|
    Disposal Damaged?        |            |
                             |            |
14. Food Contamination?      |(Yes/No/Unk)|
                             |            |                      
15. Vector/Disease Cntrl     |            |
                             |            |
a. Quarantine Area?          |(Yes/No/Unk)|
                             |            |
b. Animal Control Concerns?  |(Yes/No/Unk)|
                             |            |
c. Surveillance Activities?  |(Yes/No/Unk)|
                             |            |
d. Outbreaks?                |(Yes/No/Unk)|
                             |            |
16. HazMat/Radiological      |            |
                             |            |
a. Victims Exposed/          |(Yes/No/Unk)|
   Contaminated?             |            |
                             |            |
b. Evacuation/Shelter        |(Yes/No/Unk)|
   Issues?                   |            |
            

MENTAL HEALTH                |a. Status   |b. Remarks
------------------------------------------------------------------------------
17. Mental Health Concerns?  |(Yes/No/Unk)|
                 

OVERALL MED/HEALTH           |a. Status   |b. Remarks 
------------------------------------------------------------------------------ 
18. Critical Issues          |  (Yes/No)  |
    (and actions taken):     |            |

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

20.  POINT OF CONTACT

a. Name:                               b. Phone:  

c. Fax Number:                         d. Alt Phone: 

21. Hospital Status and Locations: (Optional information)

a. Name/Status/POC	               b. Address/Phone
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------
Name:                                  Street: 

Status: (Fully, Partially or Not       City/Zip: 
        Functional/Not Reporting)

POC:                                   Phone:
------------------------------------------------------------------------------

Created by:                       on: (date/time)

Last Modified by:                 on: (date/time)