Ics 206 Wf Form – Fill Out and Use This PDF

Enter the Incident/Project Name in box 1 and the Operational Period in box 2.

In box 3, Ambulance Services, enter the Name, Complete Address and Phone & EMS Frequency of each service.

Mark Yes or No for Advanced Life Support (ALS).

In box 4, Air Ambulance Services, enter the Name, Phone and Type of Aircraft & Capability.

In box 5, Hospitals, enter the Name, Complete Address, Travel Time (Air and Gnd) and Phone.

Enter the Lat: and Long: in GPS Datum - WGS 84, Degrees Decimal Minutes DD° MM.MMM' N - Lat DD° MM.MMM' W - Long, and the "VHF:".

Enter the Level of Care Facility and mark Helipad Yes or No.

In box 6, Division | Branch | Group, enter the Area Location Capability, EMS Responders & Capability, Equipment Available on Scene and Medical Emergency Channel.

In box 6, Division | Branch | Group, enter the Area Location Capability, then the ETA for Ambulance to Scene as Air: and Ground:, the Approved Helispot and its "Lat:" and "Long:".

In box 7, Name & Location, enter the Remote Camp Location(s).

For each one, enter the Point of Contact, EMS Responders & Capability, Equipment Available on Scene, Medical Emergency Channel, ETA for Ambulance to Scene (Air: and Ground:), Approved Helispot and "Lat:" and "Long:".

Enter Prepared By (Medical Unit Leader) in box 8 and its Date/Time in box 9, then Reviewed By (Safety Officer) in box 10 and its Date/Time in box 11.

For a medical emergency, identify the on-scene Incident Commander by name and position and announce "MEDICAL EMERGENCY" to initiate response from IMT Communications/Dispatch.

For a non-emergency incident, work through chain of command to report and transport injured personnel as necessary.

Contact Communications / Dispatch, and verify the correct frequency prior to starting the report.

Provide the incident summary (including number of patients) and command structure.

Severity of Emergency / Transport Priority: RED / PRIORITY 1 is a life or limb threatening injury or illness, and the evacuation need is IMMEDIATE. Ex: Unconscious, difficulty breathing, bleeding severely, 2o - 3o burns more than 4 palm sizes, heat stroke, disoriented. YELLOW / PRIORITY 2 is a serious injury or illness. Evacuation may be DELAYED if necessary. Ex: Significant trauma, unable to walk, 2o - 3o burns not more than 1-3 palm sizes. GREEN / PRIORITY 3 is a minor injury or illness with non-emergency transport. Ex: Sprains, strains, minor heat-related illness.

For Nature of Injury or Illness & Mechanism of Injury, enter a brief summary of the injury or illness.

For Transport Request, enter Air Ambulance / Short Haul/Hoist, or Ground Ambulance / Other.

For Patient Location, enter the Descriptive Location & Lat. / Long. (WGS84).

For Incident Name, enter the Geographic Name + "Medical".

For On-Scene Incident Commander, enter the Name of on-scene IC of Incident within an Incident.

For Patient Care, enter the Name of Care Provider.

Complete the Initial Patient Assessment for each patient as applicable, starting with the most severe patient, and enter the Treatment.

In the Transport Plan, enter the Evacuation Location (if different) as a Descriptive Location (drop point, intersection, etc.) or Lat. / Long., the Patient's ETA to Evacuation Location, and the Helispot / Extraction Site Size and Hazards.

For Additional Resources / Equipment Needs, the examples are Paramedic/EMT, Crews, Immobilization Devices, AED, Oxygen, Trauma Bag, IV/Fluid(s), Splints, Rope rescue, Wheeled litter, HAZMAT and Extrication.

Identify State Air/Ground EMS Frequencies and Hospital Contacts as applicable, entering the Channel Name/Number, Receive (RX) Tone/NAC and Transmit (TX) Tone/NAC for COMMAND, AIR-TO-GRND and TACTICAL.

For Contingency, consider what actions can be implemented in conjunction with the primary evacuation method if primary options fail, and be thinking ahead.

For Additional Information, enter Updates/Changes, etc.