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Medical Threat Assessment Form - PDF

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                                 Emergency Medical Technician – Tactical
                                   MEDICAL THREAT ASSESSMENT

OPERATION LOCATION ______________________________________ OPERATION TYPE _________________

MEDICAL RESOURCES
Local Medical Facility - Name _____________________________________ Phone _________________________
                                                                                   area code         number
Address ________________________________________________________________________________________

Point of Contact (POC) _______________________________ Title _________________ Phone __________________

Travel Time   Land ____________________ Air ______________________________

Helipad                            Yes    O   No   O      if yes,   Elevated   O   Ground       O   N/A / Off Site
                                                                                                     On
24 Hour ED                         Yes    O   No   O
Emergency Medicine Physicians      Yes    O   No   O
Dedicated MEDEVAC                  Yes    O   No   O
Comments:




Trauma Center - Name __________________________________________ Phone __________________________
                                                                                   area code         number
Address ________________________________________________________________________________________

Point of Contact (POC) _______________________________ Title _________________ Phone __________________

Travel Time   Land ____________________ Air ______________________________

Helipad                            Yes    O   No   O      if yes,   Elevated   O   Ground       O   N/A / Off Site
                                                                                                     On
24 Hour ED                         Yes    O   No   O
Emergency Medicine Physicians      Yes    O   No   O
Dedicated MEDEVAC                  Yes    O   No   O
Comments




Burn Center - Name _____________________________________________ Phone _________________________
                                                                                   area code         number
Address ________________________________________________________________________________________

Point of Contact (POC) _______________________________ Title _________________ Phone __________________

Travel Time   Land ____________________ Air ______________________________

Helipad                            Yes    O   No   O      if yes,   Elevated   O   Ground       O   N/A / Off Site
                                                                                                     On
24 Hour ED                         Yes    O   No   O
Emergency Medicine Physicians      Yes    O   No   O
Dedicated MEDEVAC                  Yes    O   No   O
Comments:




                                                   Page 1 of 6

Casualty Care Research Center                      Feb 2000 – 08                               Form 00-04.1
EMS SERVICE        Name _____________________________________________ Phone _____________________
                                                                                             area code     number
Address _________________________________________________________ _____________________________

POC ___________________________________ Title _____________________ POC Phone __________________

Travel Time     Land ____________________________________ Air ____________________________________

No. ALS Units ___________________________ No. BLS Units ___________________ No. Aircraft ___________
                  O Full Time Staffing O Call or Volunteer      O Combined Staffing

Comments




HELICOPTER PLAN Name ____________________________________________ Phone _____________________
                                                                                             area code     number
Address _________________________________________________________ _____________________________

POC ___________________________________ Title _____________________ POC Phone __________________

Flight Restrictions / Landing Zone Requirements

Location ____________________________________________                      Minimum Size _______ ft x _______ ft
Latitude _____________________ Longitude ______________                    Preferred Size _______ ft x _______ ft

Agency Policy on the following
Flight over Tactical Hot Zone          Yes        O   No   O__________________________________________
Landing in Tactical Hot Zone           Yes        O   No   O__________________________________________
Tactical Team Weapons on Board         Yes        O   No   O__________________________________________
Transport of Haz-Mat Exposure          Yes        O   No   O__________________________________________
Transport of Prisoners                 Yes        O   No   O      Handcuffed O Yes O No

      Radio Frequencies                      Tone Coded Squelch                            Call Signs



      Aircraft Type                          Number of Casualties                          Staffing




LZ Safety               Overhead Obstructions              Yes     O       No     O
                        Loose Ground Debris                Yes     O       No     O
                        Flares                             Yes     O       No     O
                        Smoke                              Yes     O       No     O
Comments




                                                  Page 2 of 6


Casualty Care Research Center                              Feb 2000 – 08                            Form 00-04.2
ENVIRONMENTAL THREATS

Weather Threats                WBGT ____________________ Flag Conditions __________ Temperature __________

Winds ______________________ Humidity _____________________ Precipitation ________________________
        speed      direction

Comments (include probability of adverse weather phenomena such as snowstorms, thunderstorms and tornados)




Heat Casualties likely     Yes     O       No             O
Rehydration Logistics      Yes     O       No             O
Uniform Adjustments        Yes     O       No             O
Work Cycles                Yes     O       No             O
Recommended water consumption per person, per hour        ______________________ quarts

Cold Casualties Likely           Yes     O       No      O
Rehydration Logistics            Yes     O       No      O
Uniform Adjustments              Yes     O       No      O
Work Cycles                      Yes     O       No      O
Shelter                          Yes     O       No      O
Aeromedical evacuation likely to be curtailed due to weather conditions ?         Yes    O       No      O



HAZARDOUS MATERIALS THREATS

Exposure to chemicals likely                        Yes   O No     O            CHEMTREC 1-800-424-9300
Are chemical stored on the property or nearby       Yes   O No     O
Are there any industrial hazards nearby             Yes   O No     O                in DC 202-483-7616


    Chemical                            ID Number                Health Hazard           Fire or Explosive Hazard




Protective clothing required                        Yes   O       No        O
Self – contained breathing apparatus required       Yes   O       No        O
Decontamination logistics                           Yes   O       No        O
Fire / Rescue HazMat team on standby                Yes   O       No        O
Comments




                                                          Page 3 of 6


Casualty Care Research Center                             Feb 2000 – 08                         Form 00-04.3
ANIMAL THREATS

Exposure to indigenous animals likely                Yes    O       No      O
If yes, specify a control strategy (consider ticks in wooded or grassy areas) __________________________________

Exposure to domestic animals / pets likely      Yes    O      No    O
If yes, specify a control strategy ____________________________________________________________________

Are guard dogs / watch dogs likely to be encountered                  Yes     O       No         O
Will police horses be utilized                                        Yes     O       No         O
Will police dogs be utilized                                          Yes     O       No         O
         See Veterinary Care Information below



BIOLOGICAL THREATS

Any threats associated with biomedical research            Yes    O     No     O
Exposure to human body fluids likely                       Yes    O     No     O
Universal precautions implemented                          Yes    O     No     O
Contamination of water likely                              Yes    O     No     O
Specify exposure control strategy ___________________________________________________________________
Comments




PLANT THREATS

Exposure to poisonous plants (poison ivy, sumac) likely               Yes     O       No         O
Uniform Adjustments                                                   Yes     O       No         O
Decontamination Logistics                                             Yes     O       No         O

OTHER SUPPORT SERVICES

VETERINARY CARE             Name _______________________________________ Phone ________________________
                                                                                                     area code        number

Address ______________________________________________________________________________________

POC _________________________________ Title ___________________ POC Phone ______________________

Travel time to facility     Land ______________________________ Air ____________________________________

Landing site or helipad at facility              Yes   O      No      O       if Yes, Elevated       O       Ground      O

Canine Services                                  Yes   O      No      O

Equine Services                                  Yes   O      No      O

Comments




                                                       Page 4 of 6


Casualty Care Research Center                                 Feb 2000 – 08                                  Form 00-04.4
PUBLIC WORKS

Street closings and routes of land travel verified         Yes     O       No   O

Comments




SOCIAL SERVICES

Are children at risk                                 Yes   O       No      O
Is a pediatric medical facility needed               Yes   O       No      O

Comments




Are social services needed                           Yes   O       No      O
Are there schools in the area                        Yes   O       No      O

POC __________________________________________________________ Phone __________________________

1. Name of School _____________________________________________ Principal _________________________

Address _______________________________________ Arrival Time _____________ Dismissal Time ___________

2.   Name of School _____________________________________________ Principal ________________________

Address _______________________________________ Arrival Time _____________ Dismissal Time ___________

Comments




ADDITIONAL COMMENTS




                                                           Page 5 of 6

Casualty Care Research Center                              Feb 2000 – 08            Form 00-04.5
                               HAZARDOUS MATERIALS DATA SHEET
HAZARDOUS MATERIAL
     Shipping Name _________________________________ DOT Hazard Class ___________________________

        Chemical Name ________________________________ ID No. ______________ STCC No. ______________

PHYSICAL DESCRIPTION
      Normal Physical Form           Solid ________ Liquid ________    Gas __________

        Color _________________ Odor _______________ Other __________________________________________

CHEMICAL PROPERTIES
      Specific Gravity _______________________________ Vapor Density ________________________________
      Boiling Point _________________________________ Melting Point _________________________________
      Vapor Pressure ___________________psi or mmHg    Expansion Ratio ______________________________
      Solubility in water     Yes O      No      O      Degree of solubility ____________________________
      Other ____________________________________________________________________________________

HEALTH HAZARDS
      Yes  Inhalation Hazard         Yes O No O    TLV / TWA ___________ppm (mg/m3) LC50 _______ ppm/hr.

        Yes     Ingestion Hazard        Yes O No O LD50 _______________ g/kg
                Absorption Hazard                         Skin
                                        Yes O No O Route N/A O Inhalation O          Eyes Yes O No O
                IDLH Value ______________ ppm/air (mg/m3)  STEL Value _________________ ppm/air(mg/m3)
                Chronic Hazards Carcinogen Yes O No O Mutagen      Yes    No Teratogen     Yes     No
                Hazardous to Aquatic Life     Yes O No O

                Other _____________________________________________________________________________

                Decontamination Procedures __________________________________________________________

            First Aid Procedures __________________________________________________________________
FIRE HAZARDS

        Yes     Flash Point ___________     Ignition (Autoignition) Temperature ___________

        No      Flammable (Explosive) Range LFL (LEL) ______________ % UFL (UEL) _____________ %

                Toxic Hazard of Combusition ___________________________________________________________

                Other ______________________ Possible Extinguishing Agents ______________________________

REACTIVITY HAZARDS
      Yes   No    Reactive with what ______________________________ Other _________________________

CORROSIVITY HAZARDS
     Yes    No   ph _______ Corrosive to what           N/A
                                                   Skin Yes No            N/A
                                                                    Steel Yes No    Other __________________

RADIOACTIVITY HAZARDS
      Yes   No    Type Radiation Emitted  None Particles
                                           Alpha
                  Other _____________________________________

RECOMMENDED PROTECTION
     For Public (Evacuation distance) ________________

        For Response Personnel (Level of Protection Required) ____________________________________________

        For Environment ___________________________________________________________________________

                                                   Page 6 of 6

Casualty Care Research Center                       Feb 2000 – 08                             Form 00-04.6

				
DOCUMENT INFO
Description: Medical Threat Assessment Form document sample