HICS-206

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ka1vgm
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HICS-206

Post by ka1vgm » Mon Mar 19, 2018 2:03 am

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
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<HEAD>
  <TITLE>HICS-206</TITLE>
  <META NAME="AUTHOR" CONTENT="w1hkj">
  <META NAME="CREATED" CONTENT="20111027">
  <META NAME="EDITABLE" CONTENT="true">
  <META NAME="MENU_ITEM" CONTENT="HICS-206">
  <title>HICS 206 - STAFF MEDICAL PLAN</title>
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</HEAD>

<BODY>
  <form>
    <TABLE WIDTH=100% cellpadding="2" cellspacing="0" border="1">
      <COL WIDTH=18%>
      <COL WIDTH=8%>
      <COL WIDTH=6%>
      <COL WIDTH=18%>
      <COL WIDTH=4%>
      <COL WIDTH=4%>
      <COL WIDTH=10%>
      <COL WIDTH=6%>
      <COL WIDTH=26%>
      <tr>
        <td COLSPAN=9>
          <p class=F3>
            <b>HICS 206 – STAFF MEDICAL PLAN</b></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=3>
          <p class=F2>
            <b>1. INCIDENT NAME</b>
            <br><input type="text" name="1" class="in1" maxlength="40" size="40" value="">
          </p>
        </td>
        <td>
          <p class=F2>
            <b>2. DATE PREPARED</b>
            <br><input type="text" name="2" class="in1" maxlength="10" size="10" value="">
          </p>
        </td>
        <td COLSPAN=3>
          <p class=F2>
            <b>3. TIME PREPARED</b>
            <br><input type="text" name="3" class="in1" maxlength="10" size="10" value="">
          </p>
        </td>
        <td COLSPAN=2>
          <p class=F2>
            <b>4. OPERATIONAL PERIOD DATE/TIME</b>
            <br><input type="text" name="4" class="in1" maxlength="30" size="30" value="">
          </p>
        </td>
      </tr>
      <tr>
        <td COLSPAN=9>
          <p class=F2>
            <b>5. TREATMENT OF INJURED / STAFF</b></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=4>
          <p class=F2>
            <b>Location of Staff Treatment Area</b>
            <br><input name="5a" value="" size="70" maxlength="70" class="in1" tabindex=t ype="text"><br>
          </p>
        </td>
        <td COLSPAN=5>
          <p class=F2>
            <b>Contact Information</b>
            <br><input name="5b" value="" size="70" maxlength="70" class="in1" tabindex=t ype="text"><br>
          </p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=4>
          <p class=F2>
            <b>Treatment Area Team Leader</b>
            <br><input name="5c" value="" size="70" maxlength="70" class="in1" tabindex=t ype="text"><br>
          </p>
        </td>
        <td COLSPAN=5>
          <p class=F2>
            <b>Contact Information</b>
            <br><input name="5d" value="" size="70" maxlength="70" class="in1" tabindex=t ype="text"><br>
          </p>
        </td>
      </tr>
      <tr>
        <td COLSPAN=9>
          <p class=F2>
            <b>Special Instructions</b></p>
          <pre><p class=F4><textarea name="5e" rows="2" cols="120" class="ta1"> </textarea></p></pre>
        </td>
      </tr>
      <tr>
        <td COLSPAN=9>
          <p class=F2><b>6. RESOURCES ON HAND</b></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=2>
          <p class=F2>
            <b>STAFF</b>
          </p>
        </td>
        <td COLSPAN=3>
          <p class=F2>
            <b>MEDICAL TRANSPORTATION </b>
          </p>
        </td>
        <td COLSPAN=3>
          <p class=F2>
            <b>MEDICATION </b>
          </p>
        </td>
        <td>
          <p class=F2>
            <b>SUPPLIES</b>
          </p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=2>
          <p class=F2>MD/DO: <input name="6staffa" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2>Litters: <input name="6medtransa" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2><input name="6meda" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="6supplya" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=2>
          <p class=F2>PA/NP: <input name="6staffb" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2>Portable: <input name="6medtransb" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2><input name="6medb" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="6supplyb" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=2>
          <p class=F2>RN/LPN: <input name="6staffc" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2>Transport: <input name="6medtransc" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2><input name="6medc" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="6supplyc" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=2>
          <p class=F2>Technicians/CN: <input name="6staffd" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2>Wheelchairs: <input name="6medtransd" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2><input name="6medd" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="6supplyd" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td COLSPAN=2>
          <p class=F2>Ancillary/Other: <input name="6staffe" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2>transother: <input name="6medtranse" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=3>
          <p class=F2><input name="6mede" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="6supplye" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr>
        <td COLSPAN=9>
          <p class=F2><b>7. ALTERNATE CARE SITE(S)</b></p>
        </td>
      </tr>
      <tr>
        <td ALIGN=CENTER>
          <p class=F2><b>NAME</b></p>
        </td>
        <td COLSPAN=5 ALIGN=CENTER>
          <p class=F2><b>ADDRESS</b></p>
        </td>
        <td COLSPAN=2 ALIGN=CENTER>
          <p class=F2><b>PHONE</b></p>
        </td>
        <td ALIGN=CENTER>
          <p class=F2><b>SPECIALTY CARE</b></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td>
          <p class=F2><input name="7namea" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"><br></p>
        </td>
        <td COLSPAN=5>
          <p class=F2><input name="7addressa" value="" size="50" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=2>
          <p class=F2><input name="7phonea" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="7carea" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td>
          <p class=F2><input name="7nameb" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"><br></p>
        </td>
        <td COLSPAN=5>
          <p class=F2><input name="7addressb" value="" size="50" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=2>
          <p class=F2><input name="7phoneb" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="7careb" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td>
          <p class=F2><input name="7namec" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"><br></p>
        </td>
        <td COLSPAN=5>
          <p class=F2><input name="7addressc" value="" size="50" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=2>
          <p class=F2><input name="7phonec" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="7carec" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr VALIGN=TOP>
        <td>
          <p class=F2><input name="7named" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"><br></p>
        </td>
        <td COLSPAN=5>
          <p class=F2><input name="7addressd" value="" size="50" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td COLSPAN=2>
          <p class=F2><input name="7phoned" value="" size="20" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
        <td>
          <p class=F2><input name="7cared" value="" size="30" maxlength="" class="in1" id="" tabindex=t ype="text"></p>
        </td>
      </tr>
      <tr>
        <td COLSPAN=9>
          <p class=F2>
            <b>8. PREPARED BY (SUPPORT BRANCH DIRECTOR):</b> <input name="8" value="" size="100" maxlength="" class="in1" id="" tabindex=t ype="text">
          </p>
        </td>
      </tr>
      <tr>
        <td COLSPAN=9>
          <p class=F2>
            <b>9. FACILITY NAME</b> <input name="9" value="" size="120" maxlength="" class="in1" id="" tabindex=t ype="text">
          </p>
        </td>
      </tr>
    </TABLE>
  </form>
</BODY>

</HTML>
--
Larry Levesque
Senior Business Systems Analyst
Granite City Electric Supply Inc.
617-221-1551 Direct
857-753-1407 Cell

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