Emergency Preparedness

Appendix H.27 – TRANSPORT LOG DISCH FORM

Kern Medical Emergency Preparedness

Form C: Transportation Log for Discharged Patients Private Vehicle #____ Name of Driver Vehicle License Number Patient #1 Name: Destination: Patient #1 Name: Destination: Patient #1 Name: Destination: Patient #1 Name: Destination: Verification Form Yes No Private Vehicle #____ Name of Driver Vehicle License Number Patient #1 Name: Destination: Patient #1 Name: Destination: Patient #1 Name: Destination: Patient #1 Name: Destination: Verification Form Yes No Private Vehicle #____ Name of Driver Vehicle License Number Patient #1 Name: Destination: Patient #1 Name: Destination: Patient #1 Name: Destination: Patient #1 Name: Destination: Verification Form Yes No

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