PATIENT TRACKING FORM (created by MSgt K. Gibbs)

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CONTAMINATED

Please note if patient is/likely may be contaminated

Yes

PATIENT'S TAG IDENTIFICATION NUMBER

Please add initials to Tag number i.e. KAG001

PATIENT DEMOGRAPHICS

Age 0-3

Age 4-12

Age 13-19

Age 20-29

Age 30-39

Age 40-55

Age 55+

MALE

FEMALE

Clear selection

TRICARE BENEFICIARY

Please note if patient is eligible for TRICARE bene

BENEFICIARY TYPE

BRANCH OF SERVICE

UNIT/SQUADRON

Do not complete unless requested by MCC during Mass Cal/Ex (use sup PII form)

TRIAGE CATEGORY

Please note patient's triage status

Delayed: condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances

Immediate: those who cannot survive without immediate treatment but who have a chance of survival

Minimal: should receive medical care at some point, after more critical injuries have been treated.

Expectant: those whose injuries are so extensive that they will not be able to survive given the care that is available

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INJURY DESCRIPTION

Unless requested by MCC do not complete

PATIENT DISPOSITION

Transported (Ambulance)

Awaiting Air Ambulance

Transported by POV (Vehicle of Opportunity)

Discharged/released

Left against medical advice

Option 6

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TRANSPORTED TO

Emergency Room

Burn Unit

ICU

Pediatric ________

Other__________________

OCH Regional Medical Center

Baptist Memorial Hospital

North Mississippi Medical Center Tupelo

Tuskaloosa VA Medical Center

Other__________________________

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DO NOT ANNOTATE SOCIAL SECURITY NUMBER OR DOB ON THIS FORM

If possible annotat patient number and note patient number, name social security number and DOB on a PII hard sheet until later time

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