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NHICS FORM 255 MASTER RESIDENT EVACUATION TRACKING FORM 1. INCIDENT NAME 2. FACILITY NAME 3. DATE PREPARED 4. RESIDENT TRACKING MANAGER 5. RESIDENT EVACUATION INFORMATION RESIDENT NAME DISPOSITION MODE OF TRANSPORTATION HOME FACILITY TRANSFER TEMP. SHELTER TIME FACILITY CONTACTED REPORT GIVEN ACCEPTING FACILITY NAME CONTACT INFO YES NO MEDICATION SENT MD/FAMILY NOTIFIED ARRIVAL CONFIRMED TIME/TRANSPORT CO. MED RECORD SENT TRANSFER INITIATED MEDICAL RECORD 6. CERTIFYING OFFICER 7. DATE/TIME SUBMITTED PURPOSE RECORD INFORMATION CONCERNING RESIDENT DISPOSITION DURING A FACILITY EVACUATION ORIGINATION OPERATIONS BRANCH COPIES TO PLANNING SECTION CHIEF AND DOCUMENTATION UNIT LEADER LEADER NHICS 255 PAGE 1 of REV. RESIDENT TRACKING MANAGER 5. RESIDENT EVACUATION INFORMATION RESIDENT NAME DISPOSITION MODE OF TRANSPORTATION HOME FACILITY TRANSFER TEMP. SHELTER TIME FACILITY CONTACTED REPORT GIVEN ACCEPTING FACILITY NAME CONTACT INFO YES NO MEDICATION SENT MD/FAMILY NOTIFIED ARRIVAL CONFIRMED TIME/TRANSPORT CO. SHELTER TIME FACILITY CONTACTED REPORT GIVEN ACCEPTING FACILITY NAME CONTACT INFO YES NO MEDICATION SENT MD/FAMILY NOTIFIED ARRIVAL CONFIRMED TIME/TRANSPORT CO. MED RECORD SENT TRANSFER INITIATED MEDICAL RECORD 6. CERTIFYING OFFICER 7. DATE/TIME SUBMITTED PURPOSE RECORD INFORMATION CONCERNING RESIDENT DISPOSITION DURING A FACILITY EVACUATION ORIGINATION OPERATIONS BRANCH COPIES TO PLANNING SECTION CHIEF AND DOCUMENTATION UNIT LEADER LEADER NHICS 255 PAGE 1 of REV. RESIDENT TRACKING MANAGER 5. RESIDENT EVACUATION INFORMATION RESIDENT NAME DISPOSITION MODE OF TRANSPORTATION HOME FACILITY TRANSFER TEMP. SHELTER TIME FACILITY CONTACTED REPORT GIVEN ACCEPTING FACILITY NAME CONTACT INFO YES NO MEDICATION SENT MD/FAMILY NOTIFIED ARRIVAL CONFIRMED TIME/TRANSPORT CO. MED RECORD SENT TRANSFER INITIATED MEDICAL RECORD 6. CERTIFYING OFFICER 7. DATE/TIME SUBMITTED PURPOSE RECORD INFORMATION CONCERNING RESIDENT DISPOSITION DURING A FACILITY EVACUATION ORIGINATION OPERATIONS BRANCH COPIES TO PLANNING SECTION CHIEF AND DOCUMENTATION UNIT LEADER LEADER NHICS 255 PAGE 1 of REV.

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