Hics 251 facility system status report




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HICS 251 – FACILITY SYSTEM STATUS REPORT

1. Operational Period Date/Time


2. Date Prepared

3. Time Prepared

4. Building Name:

5. SYSTEM STATUS CHECKLIST

COMMUNICATION SYSTEM

OPERATIONAL STATUS

COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.)

Fax

Fully functional

Partially functional

 Nonfunctional





Information Technology System (email/registration/patient records/time card system/intranet, etc.)

 Fully functional

 Partially functional

 Nonfunctional





Nurse Call System

 Fully functional

 Partially functional

 Nonfunctional





Paging - Public Address

 Fully functional

 Partially functional

 Nonfunctional





Radio Equipment

 Fully functional

 Partially functional

 Nonfunctional





Satellite System

 Fully functional

 Partially functional

 Nonfunctional





Telephone System, External

 Fully functional

 Partially functional

 Nonfunctional





Telephone System, Proprietary

 Fully functional

 Partially functional

 Nonfunctional





Video-Television-Internet-Cable

 Fully functional

 Partially functional

 Nonfunctional





Other

 Fully functional

 Partially functional

 Nonfunctional





INFRASTRUCTURE SYSTEM

OPERATIONAL STATUS

COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.)

Campus Roadways

 Fully functional

 Partially functional

 Nonfunctional





Fire Detection/Suppression System

 Fully functional

 Partially functional

 Nonfunctional





Food Preparation Equipment

 Fully functional

 Partially functional

 Nonfunctional





Ice Machines

 Fully functional

 Partially functional

 Nonfunctional





Laundry/Linen Service Equipment

 Fully functional

 Partially functional

 Nonfunctional





Structural Components (building integrity)

 Fully functional

 Partially functional

 Nonfunctional





Other

 Fully functional

 Partially functional

 Nonfunctional





PATIENT CARE SYSTEM

OPERATIONAL STATUS

COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.)

Decontamination System (including containment)

 Fully functional

 Partially functional

 Nonfunctional





Digital Radiography System (e.g., PACS)

 Fully functional

 Partially functional

 Nonfunctional





Ethylene Oxide (EtO)/Sterilizers

 Fully functional

 Partially functional

 Nonfunctional





Isolation Rooms (positive/negative air)

 Fully functional

 Partially functional

 Nonfunctional





Other

 Fully functional

 Partially functional

 Nonfunctional





SECURITY SYSTEM

OPERATIONAL STATUS

COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.)

Door Lockdown Systems

 Fully functional

 Partially functional

 Nonfunctional





Surveillance Cameras

 Fully functional

 Partially functional

 Nonfunctional





Other

 Fully functional

 Partially functional

 Nonfunctional





UTILITIES, EXTERNAL SYSTEM

OPERATIONAL STATUS

COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.)

Electrical Power-Primary Service

 Fully functional

 Partially functional

 Nonfunctional





Sanitation Systems

 Fully functional

 Partially functional

 Nonfunctional





Water

 Fully functional

 Partially functional

 Nonfunctional


(Reserve supply status)

Natural Gas

 Fully functional

 Partially functional

 Nonfunctional





Other

 Fully functional

 Partially functional

 Nonfunctional





UTILITIES, INTERNAL SYSTEM

OPERATIONAL STATUS

COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.)

Air Compressor

 Fully functional

 Partially functional

 Nonfunctional





Electrical Power, Backup Generator

 Fully functional

 Partially functional

 Nonfunctional


(Fuel status)

Elevators/Escalators

 Fully functional

 Partially functional

 Nonfunctional





Hazardous Waste Containment System

 Fully functional

 Partially functional

 Nonfunctional





Heating, Ventilation, and Air Conditioning (HVAC)

 Fully functional

 Partially functional

 Nonfunctional





Medical Gases, Other

 Fully functional

 Partially functional

 Nonfunctional





Oxygen

 Fully functional

 Partially functional

 Nonfunctional


(Reserve supply status)

Pneumatic Tube

 Fully functional

 Partially functional

 Nonfunctional





Steam Boiler

 Fully functional

 Partially functional

 Nonfunctional





Sump Pump

 Fully functional

 Partially functional

 Nonfunctional





Well Water System

 Fully functional

 Partially functional

 Nonfunctional





Vacuum (for patient use)

 Fully functional

 Partially functional

 Nonfunctional





Water Heater and Circulators

 Fully functional

 Partially functional

 Nonfunctional





Other

 Fully functional

 Partially functional



 Nonfunctional




6. CERTIFYING OFFICER

7. FACILITY NAME




Purpose: Record facility status for operational period for incident Origination: Infrastructure Branch Director HICS 251

Original to: Situation Unit Leader Page of

Copies to: Safety Officer, Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, and Documentation Unit Leader


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