Form Ics 204 – Fill Out and Use This PDF

1.

Incident Name:

2. Operational Period:

3.

Date From:

Date To:

Branch:

1

Time From:

Time To:

1

4.

Operations Personnel: Name

Contact Number(s)

Division:

Operations Section Chief:

Group:

1

Branch Director:

Staging Area: 1

Division/Group Supervisor:

5.

Resources Assigned:

# of Persons

Reporting Location,

Contact (e.g., phone, pager, radio

Special Equipment and

Supplies, Remarks, Notes,

Resource Identifier

Leader

frequency, etc.)

Information

6.

Work Assignments:

7.

Special Instructions:

8.

Communications (radio and/or phone contact numbers needed for this assignment):

Name/Function

Primary Contact: indicate cell, pager, or radio (frequency/system/channel)

/

/

/

/

9. Prepared by: Name:

Position/Title:

Signature:

ICS 204

IAP Page _____

Date/Time:

Block

Block Title

Instructions

Number

1

Incident Name

Enter the name assigned to the incident.

2

Operational Period

Enter the start date (month/day/year) and time (using the 24-hour

• Date and Time From

clock) and end date and time for the operational period to which the

• Date and Time To

form applies.

3

Branch

This block is for use in a large IAP for reference only.

Division

Write the alphanumeric abbreviation for the Branch, Division, Group,

Group

and Staging Area (e.g., “Branch 1,” “Division D,” “Group 1A”) in large

Staging Area

letters for easy referencing.

4

Operations Personnel

Enter the name and contact numbers of the Operations Section Chief,

•

Name, Contact Number(s)

applicable Branch Director(s), and Division/Group Supervisor(s).

–

Operations Section Chief

–

Branch Director

–

Division/Group Supervisor

5

Resources Assigned

Enter the following information about the resources assigned to the

Division or Group for this period:

•

Resource Identifier

The identifier is a unique way to identify a resource (e.g., ENG-13,

IA-SCC-413). If the resource has been ordered but no identification

has been received, use TBD (to be determined).

•

Leader

Enter resource leader’s name.

•

# of Persons

Enter total number of persons for the resource assigned, including the

leader.

• Contact (e.g., phone, pager,

Enter primary means of contacting the leader or contact person (e.g.,

radio frequency, etc.)

radio, phone, pager, etc.). Be sure to include the area code when

listing a phone number.

5

•

Reporting Location, Special

Provide special notes or directions specific to this resource. If

(continued)

Equipment and Supplies,

required, add notes to indicate: (1) specific location/time where the

Remarks, Notes, Information

resource should report or be dropped off/picked up; (2) special

equipment and supplies that will be used or needed; (3) whether or not

the resource received briefings; (4) transportation needs; or (5) other

information.

Block

Block Title

Instructions

Number

6

Work Assignments

Provide a statement of the tactical objectives to be achieved within the

operational period by personnel assigned to this Division or Group.

7

Special Instructions

Enter a statement noting any safety problems, specific precautions to

be exercised, dropoff or pickup points, or other important information.

8

Communications (radio and/or

Enter specific communications information (including emergency

phone contact numbers needed

numbers) for this Branch/Division/Group.

for this assignment)

If radios are being used, enter function (command, tactical, support,

•

Name/Function

etc.), frequency, system, and channel from the Incident Radio

•

Primary Contact: indicate

Communications Plan (ICS 205).

cell, pager, or radio

(frequency/system/channel)

Phone and pager numbers should include the area code and any

satellite phone specifics.

In light of potential IAP distribution, use sensitivity when including cell

phone number.

Add a secondary contact (phone number or radio) if needed.

9

Prepared by

Enter the name, ICS position, and signature of the person preparing

•

Name

the form. Enter date (month/day/year) and time prepared (24-hour

•

Position/Title

clock).

•

Signature

•

Date/Time