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Methodist Hospital

Emergency Incident Message Form

Use this form to submit your Initial check in with the Command Center every time an emergency situation is announced.
All departments/units who do not submit a "Patient Unit Report" at the start of a DRS' ALERT PH I or II must include their staffing level on this form.
Associated Event   
This form is used to report departmental information directly to Command Center. (telephone extensions 7501 & 7502
  Emergency Status
Is Department ready to accept emergency victims/patients?
YES     NO     NA    
* Department
  Surge Capacity
Empty beds available on this unit for expansion?
YES     NO     NA    
* Reported by
* Telephone ext. # of
  Date & Time:
* Priority of Message URGENT(top)     NON-URGENT(moderate)     INFORMATIONAL(low)    
* Total Staff Members Available
  Number of RNs (if applicable)
* Message:
Please be descriptive and include all known details, names of those involved, time occurred, etc.
* Additonal comments: