Ics Form 206 - Medical Plan
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3MEDICAL PLAN (ICS 206)
1. Incident Name:
2. Operational Period: Date From:
Date To:
Time From:
Time To:
3. Medical Aid Stations:
Contact
Paramedics
Name
Location
Number(s)/Frequency
on Site?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
4. Transportation (indicate air or ground):
Contact
Ambulance Service
Location
Number(s)/Frequency
Level of Service
ALS BLS
ALS BLS
ALS BLS
ALS BLS
5. Hospitals:
Address,
Contact
Travel Time
Latitude & Longitude
Number(s)/
Trauma
Burn
Hospital Name
if Helipad
Frequency
Air
Ground
Center
Center
Helipad
Yes
Yes
Yes
No
No
Level:_____
Yes
Yes
Yes
No
No
Level:_____
Yes
Yes
Yes
No
No
Level:_____
Yes
Yes
Yes
No
No
Level:_____
Yes
Yes
Yes
No
No
Level:_____
6. Special Medical Emergency Procedures:
Check box if aviation assets are utilized for rescue. If assets are used, coordinate with Air Operations.
7. Prepared by (Medical Unit Leader): Name:
Signature:
8. Approved by (Safety Officer): Name:
Signature:
ICS 206
IAP Page _____
Date/Time:
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