CHCANYS’ CHC Situational Report (SitRep) – ICS 209 HC.CHC NY
Date / Time / Initial Update Final[ ] [ ] [ ] / CHC Name / CHC Site Name
Incident Name / Incident Type / Start Date/Time / Cause
Short Description of Incident
Current Community Situation
Size of Area Involved / Declared Disaster
Yes [ ] No [ ] / Estimated Casualties / Injuries to Date / Fatalities Reported
Threat to Life Safety in Community / Number Involved / Area Healthcare Centers Surging
Evacuations In Progress / Yes [ ]
No [ ] / HC Name / Surging / At Capacity / Overrun
Imminent Evacuations / Yes [ ]
No [ ] / 1.
Potential Future Threat / Yes [ ]
No [ ] / 2.
No Likely Threat / Yes [ ]
No [ ] / 3.
Type of Services Requested
[ ] Primary Care [ ] OB/GYN [ ] Psychiatry/Psychology [ ] PTSD Counseling [ ] Social Work [ ] Pediatrics [ ] Vaccinators
[ ] Clerical [ ] Medical Volunteers [ ] POD [ ] Messaging for Worried Well [ ] Specialists: ______
[ ] Shelter Volunteers [ ] Other: ______
CHC Situation
CHC Capabilities Threatened By Current Situation:
CHC is able to provide the following services:
(Please provide the number of patients the CHC is able to accept)
Service No. Service No. / Provide the number of Volunteers the CHC is able to provide:
Volunteer Type No.
[ ] Primary Care / [ ] PTSD Counseling / Medical
[ ] OB/GYN / [ ] Social Work / POD
[ ] Pediatrics / [ ] Specialists / Shelter
[ ]Psychiatry/Psychology / [ ] Vaccinations/Prophylactic / Clerical
[ ] Worried Well / [ ] Other / Other
CHC Status
CHC Needs
Current # of Patients / Total Surge Capacity / No. of Physicians / No of RNs / Services Operating
[ ] Lab [ ] Radiology / Volunteers Needed
[ ] Yes [ ] No
CHC Rep Name / Site / PCEPN Name / Signature / Reviewed By: / Time