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 T....
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How to fill out the Nhics 255 online
The Nhics 255 form is essential for accurately tracking resident evacuation information during an emergency. This guide provides clear instructions for completing the form to ensure all necessary details are recorded accurately.
Follow the steps to complete the Nhics 255 form online.
- Press the ‘Get Form’ button to obtain the form and open it in the editor.
- In the first section, enter the incident name in the designated field. This identifies the specific event associated with the evacuation.
- Next, provide the facility name where the residents are located, ensuring accuracy for better tracking.
- Fill in the date prepared to indicate when the form was completed. This is crucial for record-keeping.
- Identify the resident tracking manager responsible for overseeing the evacuation. Include their contact information for accountability.
- For each resident, fill in their name and specify their disposition, indicating where they have been transported (home, facility transfer, or temporary shelter).
- Record the mode of transportation used for each resident in the relevant section.
- Document the time the facility was contacted and report information given regarding the evacuation.
- Provide the name and contact information for the accepting facility where each resident is being transferred.
- Indicate whether the resident's medical records were sent, and whether their medication was also transferred.
- Confirm if the family or medical doctor was notified about the resident's transportation and if their arrival has been confirmed, including timestamps.
- Repeat the above steps for additional residents as needed, ensuring each entry is complete and accurate.
- Complete the certification section by entering the certifying officer's name and the date and time the form is submitted.
- After all sections are filled, save changes, download, print, or share the form as required.
Start filling out the Nhics 255 form online to ensure proper resident tracking during an evacuation.
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