Emergency Preparedness

Appendix H.25 – PATIENT EVAC INFO FORM

Kern Medical Emergency Preparedness

Form A: Patient Evacuation Information

Note: Items in BOLD are required information.

Sending Hospital Evacuation Acuity Level

1 2 3 4

Patient Name Patient Medical Record Number Receiving Facility (if known) Time Discharged from Assembly Area Equipment Sent with Patient Family Notification Name of Primary Attending Physician Diagnosis Type of Isolation

Yes No

Contact Droplet Airborne

Special Considerations and Precautions

Other Information and Directives

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