Region 2 - Incident Situation Report
This form is to be used to update the Illinois Region 2 RHCC or the Region 2 Medical Response Team on an emergent situation in Illinois Region 2. This form is brief in format and should be as specific as possible. If this is a new Emergency then please contact the Region 2 RHCC as soon as possible. The intent of this form is to send updates, not to report an Emergency. If you have a request for resources. Please complete the "Request for Medical Resources" form on our website.
Sign in to Google to save your progress. Learn more
Reporting Facility - *
The facility (Hospital/Medical Center) that is filling out this report.
Representative completing this report - *
Name of the representative from the facility that is completing this form.
Representative Contact Information - *
Contact information including name, e-mail, phone number (direct number, cell phone or extension)
Alternate Representative Contact Information
Contact information for an alternate representative in the event the primary is unavailable. Include, name, e-mail, phone number (direct number or extension)
Description of current situation - *
Please describe the situation as best as possible
Needs that have not been filled - *
Please descibe any needs that have not or can not be filled by your local resources (Fire, Police, EMS, EMA, ESDA, etc)
Any other information -
Do you need a representative to contact you? *
Although this form is not intended to be a basis of contact in the event of an emergency. If you have information you feel is "Not for Public Disclosure" please let us know and we can contact you.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms