Contents
Appendix 1 – Acronyms .................................................................................................................. 3
Appendix 2 – Triage Guidelines for Admission to a Medical Needs Shelter .................................. 5
2.1 – Level of Care Triage Matrix ............................................................................................. 8
Appendix 3 – Staffing and Organization ....................................................................................... 11
3.1 - MNS Organization Chart ................................................................................................ 13
3.2 – MNS Staff Job Action Sheets......................................................................................... 15
Appendix 4 – MNS Site Locations ................................................................................................. 55
4.1 – Floor Plans .................................................................................................................... 56
Appendix 5 – Memorandum of Agreement between [County] and [Facility Name] ................... 57
Appendix 6 – County Support Service Providers .......................................................................... 59
Appendix 7 – Supply List ............................................................................................................... 61
Appendix 8 – Site Forms ............................................................................................................... 67
Appendix 9 – Waivers ................................................................................................................... 83
Appendix 10 – Sample Media Release .......................................................................................... 84
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Appendix 1 – Acronyms
ARC – American Red Cross
CERT – Community Emergency Response Teams
DHSS – Department of Health and Senior Services
EMS – Emergency Medical Services
EOC – Emergency Operations Center
EOP – Emergency Operations Plan
ESF – Emergency Support Function
JIC – Joint Information Center
MCC – Medical Coordination Center
MNS – Medical Needs Shelter
OEM – Office of Emergency Management
SOG – Standard Operating Guideline
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Appendix 2 – Triage Guidelines for Admission to a Medical
Needs Shelter
A basic Medical Needs Population will be initially defined as individuals who meet the following criteria:
1. Unable to make medical sheltering arrangements through his/her own resources or facility
arrangements; AND
2. Not acutely ill; AND
3. Has one or more medical condition(s) that require a level of medical care or assistance that
exceeds what a general shelter is able to provide.
While the above criteria must be met in order to be initially considered for triage to a Medical Needs
Shelter (MNS), both community shelters and MNSs are understood to be continually evolving, and an
evacuee (patient) initially admitted to an MNS may be reevaluated and reassigned to a community
shelter and vice versa. In addition, triage personnel will use a needs-based approach to consider the
severity and required assistance of an evacuee’s (patient’s) condition or disease instead of the condition
or disease itself. Consideration will also be given if a caregiver or assistant is present and is capable of
providing basic medical needs in a community shelter.
Immediate family or caregivers may be permitted to accommodate the evacuee (patient) admitted into
an independently located MNS at the discretion of the Site Coordinator and Triage Officer. Evacuee
(patient) circumstances, availability of basic resources, and accommodations must be taken into account
when evaluating the possibility of allowing a family member or caregiver to accompany the evacuee
(patient) in an MNS.
The following pre-screening guidelines may be followed. This is not an all-encompassing list, and
additional guidelines may be established as deemed necessary by the Triage Officer and Site
Coordinator:
1. Population identified for relocation
a. Medical needs in either:
i. General community
ii. Institutional community
2. Populations that will not be relocated to an MNS:
a. Acute medical conditions
b. Conditions requiring isolation or quarantine
c. Life-threatening medical conditions
3. Specialty Populations
a. Certain specialty populations (e.g., pediatrics, psychiatrics) may or may not be
admitted to the MNS at the discretion of the Triage Officer and Site Coordinator
on the basis of the evacuee’s (patient’s) needs and the availability of specialty
personnel. If a specialty population is not recommended for admittance to the
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MNS, they may be reprioritized as Community Shelter (Tier 1) or Hospital
Facility (Tier 3).
4. Expectations for Incoming:
a. Institutionalized: Physician’s orders (which will be taken into consideration by
MNS medical direction), staff, and equipment must be from the institution.
b. Non-institutionalized: Medical direction, staff, and equipment will come from a
municipal/county agency, a regional source, or other.
MNS/Community Shelter Nursing Station Dual Function: For those functional need evacuees (patients)
in a co-located MNS/community shelter who do not require continual medical evaluation and
supervision but do require minimal supervision for basic medical needs (e.g., assisted medications,
monitoring blood glucose levels, etc.), a scheduling and appointment system may be instituted to
facilitate such basic medical needs. Additional staffing needs include one additional Registered Nurse
and one additional Administrative Support person.
The Triage Officer will assign evacuees (patients) according to the following tier system1:
1. Community or American Red Cross Shelter – Tier 1
a. Definition – Individuals who are independent prior to the disaster or emergency.
Some of these individuals may have pre-existing health problems that do not
impede activities of daily living and do not exceed the basic first aid capabilities of
community shelters.
b. Examples of pre-existing conditions that can be accommodated within a traditional
shelter include:
 Epilepsy when controlled
 Controlled insulin-dependent diabetic
 Hemophilia
 Ostomies self-care
 Vision or hearing impairments
 Prosthesis
 Dry wounds requiring basic maintenance by evacuee
 Asthma if controlled
 Functional needs: Wheelchair-bound person or person with other mobilityrelated disabilities without other medical needs who is able to use the
shower or facilities with minimal assistance
 Conditions controlled by self-administered medications
 Persons requiring dialysis
c. Caveats:
 Persons who have more complex medical needs but who have a caretaker
who will stay in the shelter with them may be able to safely stay in a general
shelter and not require a higher level of care in an MNS.
1
Based on the Spokane Regional Health District MNS Plan, Washington State, May 2009.
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2. Medical Needs Shelter - Tier 2
a. Definition – Evacuees (patients) who have no acute medical conditions but require
some medical surveillance and/or special assistance beyond what is available in a
traditional shelter.
b. Examples of conditions that can be accommodated with an MNS include:
 Conditions listed in Tier 1 that are not evacuee (patient)-controlled
 Wheelchair-bound person with medical needs
 Tracheotomy
 Feeding tube
 PICC lines
 Oxygen-dependent person and other oxygen issues
 Draining wounds requiring frequent sterile dressing changes
 Persons whose disability prevents them from sleeping in a cot
 Hospice patients
c. Caveats:
 Individuals who were homebound with a caregiver should have their
caregiver stay in the shelter with them and bring any necessary medical
supplies.
 Persons suspected of having a communicable illness based on medical
history, symptoms (fever, rash, diarrhea, or vomiting), or examination at
triage should be taken to a nearby hospital for evaluation and treatment.
3. Hospital Facility –Tier 3
a. Definition – Evacuees (patients) who need acute medical care such as individuals
experiencing significant trauma, injury, or have acute medical condition(s).
b. Examples of conditions that should be seen only in a hospital include:
 Evacuees (patients) who are ventilator dependent
 Pregnancy (gestation >32 weeks or multiple/twin >30 weeks)
 Pregnant women who are having contractions or are in labor
 Persons reporting chest pain any time in the last 24 hours or are suspicious
of chest pain that is cardiac in nature
 Acute altered mental status (e.g., lethargic, disoriented, etc.)
 Comatose individuals
 Uncontrollable or violent persons
 Contagious conditions that require special precautions
 Persons with acutely infected wounds
 Bedridden but stable and able to swallow
 Others requiring the intensity of service only provided at a hospital
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c. Caveats:
 Evacuees (patients) with a specialty condition (e.g., pediatrics, obstetrics,
psychiatry) may be reprioritized as Tier 3 at the discretion of the Triage
Officer and Site Coordinator.
2.1 – Level of Care Triage Matrix
The following Level of Care Triage Matrix represents common conditions that may be encountered in an
MNS Triage situation and serves as a guide for tier categorization:
Level of Care Triage Matrix
Condition
2
Medical Needs
Shelter
(Tier 2)
Community Shelter
(Tier 1)
Hospital Facility
(Tier 3)
Alzheimer’s disease (ALZD)
Early to Moderate,
cooperative,
not a flight risk
Bedridden without
personal assistance
services
Advanced. Bedridden,
nonverbal,
refusal to eat, totally
dependent
Ambulation (walker,
cane, crutches, wheelchair)
 Arthritis
 Osteoarthritis/Osteoporosis
 Parkinson’s Disease
 Multiple Sclerosis
 Muscular Dystrophy
 Neuromuscular Disorders
Ambulates with or
without assistance
Bedridden without
personal assistance
services
Bedridden with acute disease
process (Hospital), requires
pain management
Bedridden without
personal assistance
services
Advanced, bedridden, totally
dependent
Aphasia (communication
difficulty)
Wheelchair bound,
able to transfer from
chair to bed
Assistant or caregiver
present
Bronchitis
Inhalers
Cardiac
Stable, oral meds
Cerebral Palsy
Stable
Ameliorating Lateral Sclerosis
(ALS) (wheelchair)
2
If requires nebulizer
treatments
Controlled with
medications
Bedridden without
personal assistance
services
Unstable, requires urgent
medical evaluation, O2 sat
below %
Unstable, having shortness of
breath & Angina
Severe, bedridden, totally
dependent
Spokane Regional Health District MNS Plan, Washington State, May 2009, and
Guide to Medical Needs Shelters: A Guide for Local MRC Units, Medical Reserve Corps.
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Colostomy/Ileostomy
Managed by person
or personal assistant
Evacuee (patient)
unable to manage
ostomy care and does
not have personal
assistant
Comatose
Contagious, severe infection
Continuous Ambulatory
Peritoneal Dialysis (CAPD)
Post-surgical ostomy,
exacerbation of condition
resulting in medical need for
surgery or hospitalization (e.g.,
infection)

Hepatitis, Tuberculosis,
Measles,
or mumps in adult

Cystic Fibrosis
Stable
Dementia
Able to follow
instructions, not a
flight risk –
monitored by
assistant or caregiver
End stage, bedridden
Diabetes/Hyperglycemia
Insulin and diet
controlled, insulin
administration
assistant monitoring
Brittle diabetic, glucose over on
dialysis
Dialysis (hemo and peritoneal)
Stable with schedule
compliance
Eating and Swallowing
Disorders
Needs meds
Eating disorder
under control,
require
assistance/tube
feeding
Dialysis schedule
disruption, anticipate
symptoms
Pump feedings
Swallowing disorders
requiring thickeners
and gastric feedings
Edema
Mild, related to
position or non-acute
injury as in a sprain
Related to mild CHF
and position
Foley Catheter
Stable
Management & Foley
change
Fractured Bones
Dressing changes
Pin site care
High Blood Pressure/
Hypertension
Stable
Monitor, assistance
with medications
Hip Replacement
>6 months
<6 months
Knee replacement
>6 months
<6 months
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Respiratory Compromise
Symptomatic
No gag reflex, history of
aspiration,
requires suction airway
management, exacerbation of
condition resulting in medical
need for surgery or
hospitalization
Acute CHF or other metabolic
condition requiring urgent
medical management
Catheter management postsurgical procedure
Acute injury requiring
monitoring and pain
management
Uncontrolled, requires urgent
medical management
Medical Equipment
Attachments
Migraine Headaches
Post Cerebrovascular Accident
(CVA)
Psychosis
G-Tubes

Minor/Stable – Feeds
and ambulates
without assistance
Controlled
Wheelchair bound,
able to transfer from
chair to bed
Controlled
Respirator Ventilator
Dependent
IV, NG –Tubes, Central Venous
Catheters or Tracheotomy
Tube (newly placed or requires
frequent suctioning)
Bedridden
Uncontrolled

Respiratory
 Asthma/Chronic Obstructive
Pulmonary Disease (COPD)
 Emphysema
Oxygen-dependent
stable conditions,
stable respiratory
treatments
(nebulizer, asthma
inhaler)
Seizures
Controlled
Skin Rashes
Sores/Non-fluid
Sleep Apnea
Non-electric
dependent, Electric
dependent, CPAP
Upper Respiratory Infection

Isolation
Requires urgent medical
evaluation,
Fever/O2 sat %
Urinary Tract Infection

Mobile with minimal
assistance
Wheelchair bound
with other conditions
Bed bound
Wheelchair Transferable
Stable, ventilatordependent O2
therapies
administered by skilled
provider (e.g.,
respiratory therapist)
Med assistance
needed
Open sores, draining,
dressing changes
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Unstable respiratory conditions,
unstable ventilator dependent,
stable In-SMN skilled nursing
Uncontrolled
Infectious
Appendix 3 – Staffing and Organization
The number and types of medically trained staff are based on 12-hour shifts and care for 25 patients.
Title
Site Coordinator
Number
Required
1
Specific Qualifications
Experienced manager of
medical care facility
Experience in logistics
procedures and set-up
of MNS.
Experience in logistics
procedures and supply
inventory
Law enforcement or
security training
General administrative
responsibilities and
maintenance of all MNS
records.
Logistics Section
Chief
1
Resource Manager
1
Security Officer
2
Administrative
Section Chief
1
Administrative
Support
1
General administrative
responsibilities.
Case Manager
1
Experience in social
work
Operations Section
Chief
1
Registered Nurse
Triage Officer
Registered Nurse
(RN)
1
1
Reports to
Overall management of MNS
County EOC [ESF#6]
Establishment and set-up of
MNS. Provide support
services. Request needs.
Site Coordinator
Ensure adequate supplies to
maintain MNS operations
Logistics Section
Chief
Maintain safety and security
of MNS patients and staff
Patient registration, staffing
and volunteer support,
financial and staffing
reporting
Provide administrative
support functions
throughout the MNS
Family support, discharge
planning
Provide oversight of patient
care and proper medical
treament
Logistics Section
Chief
Site Coordinator
Administrative
Section Chief
Administrative
Section Chief
Site Coordinator
Registered Nurse or
higher
Triage incoming patients for
appropriate care. Consult
with Operations Section
Chief and Patient Care
Technicians to re-triage
patients on a regular basis.
Provide direct patient care
when not triaging patients.
Operations Section
Chief
Registered Nurse
Provide direct patient care in
accordance with generally
accepted patient care
procedures and protocols.
Operations Section
Chief
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Responsibilities
Licensed Practical
Nurse (LPN)
1
LPN
Patient Care
Technician
3
Certified Nursing
Assistant or higher
Pharmacy
1
Certified Pharmacist
Mental Health
Counselor
1
Mental health
professional
EMS Transport Crew
1
Proper EMS
Certifications (e.g. EVOC,
EMT (B), etc.)
Clergy
1
Ordained Clergy
Member
Provide direct patient care in
accordance with generally
accepted patient care
procedures and protocols.
Provide general assistance to
the nursing staff in caring for
patients.
Maintenance and
distribution of medicine to
evacuee (patients)
Provide counseling services
to MNS patients and staff.
Provide initial lifesaving
actions and transportation to
and from other health
facilities
Assess and assist in the
spiritual health needs of the
evacuee (patients)
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Operations Section
Chief
Operations Section
Chief
Operations Section
Chief
Operations Section
Chief
Operations Section
Chief
Operations Section
Chief
3.1 - MNS Organization Chart
MNS Site
Coordinator
Administrative
Section Chief


Administrative Support 
Case Manager

Operations
Section
Chief
Logistics
Section Chief
Resource Manager
Security Officer(s)








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Triage Officer (RN or higher)
RN (1)
LPN (1)
Evacuee (Patient) Care
Technician (3)
Pharmacy
Mental Health Counselor
EMS Transport Crew
Clergy
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3.2 – MNS Staff Job Action Sheets
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MNS Site Coordinator
Job Action Sheet
To establish and oversee setup and operations of MNS.
Reports to: [county/municipality/agency]
Required Qualifications: Experienced manager of medical care facility
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
List of available resources
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support Staff
Put on nametag
Review the job action checklist
Review plans and SOGs
Perform a pre-activation site walk-through with a
representative of the host facility and (if co-located) a
representative of the community shelter
Develop and plan space at location
Develop initial staffing schedule for first 12 hours
Delegate responsibilities and check sheets to each
team leader
Monitor the MNS setup and alert
[county/municipality/agency] to additional activation
needs
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REFERENCE
Complete a check and verify that the shelter is ready
for operation before it opens to the public
Communicate with the [county/municipality/agency]
when MNS is ready to receive evacuees (patients)
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Develop staffing schedules for the next 24 hours
Assign personnel within designated area
Anticipate unmet needs and communicate with
support staff and [county/municipality/agency]
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Continue to monitor situation and determine current
and future resource needs
Conduct regular shift reviews to update shelter
operations and needs
Provide status reports to [Municipal/County EOC and
the [Emergency Support Function (ESF) #6] desk to
maintain situational awareness
Maintain a staffing schedule for continuous coverage
of all vital functions for the next 72 hours
Maintain communications with Administrative and
Logistics Section Chiefs
Work with medical support staff to ensure
appropriate care
Provide evacuee (patient) census to [County Health or
Office of Emergency Management (OEM)]
Observe all evacuees (patients) and staff for stress
and fatigue.
Sign out upon completion of your MNS shift
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REFERENCE
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Coordinate with facility and
[municipality/county/agency] to demobilize
operations and return to normal activities
Through the [county/municipality/agency], assist with
transitioning evacuees (patients) from MNS back to
their homes or to temporary housing
Account for all staff
Ensure that all personnel are properly debriefed, to
include mental health debriefings, if appropriate
Remind staff to clean up areas upon termination
Perform a demobilization site walk-through with a
representative of the host facility and (if co-located) a
representative of the community shelter
Complete a damage report, as necessary
Ensure that any open actions not yet completed will
be handled after demobilization
Participate in and/or complete after-action
requirements
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REFERENCE
Logistics Section Chief
Job Action Sheet
To serve as the primary staff officer for the Site Coordinator for all matters concerning logistics.
Reports to: Site Coordinator
Required Qualifications: Experience in logistics procedures and setup of MNS.
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Supplies checklist
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
Set up MNS to receive evacuees (patients)
Communicate with the Site Coordinator when MNS
is ready to receive evacuees (patients)
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REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Anticipate unmet needs and communicate with Site
Coordinator
Work with security officer(s) to establish MNS
security perimeter
Post security staff on outside doors and for fire
watch, if available
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Establish and maintain contact with the facility
operator to ensure that facility mechanical systems
are in working order
Participate in shift reviews to assess needs of MNS
Oversee housekeeping, trash, and medical waste
disposal
Ensure disposal of trash and medical waste
Ensure that regular housekeeping activities are
completed
Ensure that emergency aisles and exits are clear
Work directly with [county, municipality, agency] to
ensure that adequate food service is provided for
evacuees (patients)
Work directly with [county, municipality, agency] to
ensure that adequate food service is provided for
evacuees (patients) with specific dietary needs
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Review records and completed law enforcement
forms for any security incident occurring within the
MNS and file with Administrative Officer, if necessary
Sign out upon completion of MNS shift
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REFERENCE
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Track and account for all equipment and supplies
during demobilization
Remind personnel to clean up areas upon
termination
Assess and coordinate supply restock, as needed
Ensure that any open actions not yet completed will
be handled after demobilization
Participate in staff debriefing, to include mental
health debriefings, if appropriate
Participate in and/or complete after-action
requirements
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REFERENCE
Resource Manager
Job Action Sheet
To maintain adequate supplies and equipment for MNS functioning.
Reports to: Logistics Officer
Required Qualifications: Experience in logistics procedures and supply inventory
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant supply sheets
Pens/Pencils
Supplies checklist
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Anticipate unmet needs and communicate with
Logistics Section Chief
Complete an initial general supplies check and verify
that the shelter is ready for operation
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REFERENCE
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Communicate needs with Logistics Section Chief to
maintain situational awareness
Maintain an inventory checklist of supplies used and
supplies remaining
Reorder supplies as needed
Document any resources that are taken from the host
facility
Coordinate with the Logistic Section Chief for special
resource requests (e.g., advanced medical equipment
or supplies)
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Review and organize supply invoices and remaining
supply inventory
Complete a final supplies inventory for the Logistics
Section Chief
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
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REFERENCE
Security Officer
Job Action Sheet
To maintain safety and security of MNS evacuees (patients) and staff.
Reports to: Logistics Officer
Required Qualifications: Law enforcement or security training
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant security devices
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
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REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Work with Logistics Officer to establish MNS security
perimeter
Post security staff at entrance to MNS
Post security staff on outside doors and for fire watch,
if available
Post security staff outside of pharmacy area
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Maintain situational awareness with the Logistics
Section Chief
Maintain security and safety of staff and occupants
Control access to MNS staff, evacuees (patients), family
members/caregivers
Assist in locating lost persons and/or property
Monitor parking and drop-off areas
Observe all staff and evacuees (patients) for signs of
stress and inappropriate behavior; report concerns to
Site Coordinator
Complete relevant law enforcement reports for any
security incident occurring within the MNS, and file
with the Logistics Officer, if necessary
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
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REFERENCE
Administrative Section Chief
Job Action Sheet
1. To oversee the administrative support of MNS.
2. To act as a liaison between MNS and [County Health or OEM].
Reports to: Site Coordinator
Required Qualifications: General administrative responsibilities and maintenance of all MNS
records
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Supplies checklist
Contacts list
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Assist the Site Coordinator in developing and planning
space at location
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July 2012
REFERENCE
Assist the Site Coordinator in developing initial staffing
schedule for first 12 hours
Complete an initial administrative supplies check and
verify that the shelter is ready for operation
Communicate with the Site Coordinator when MNS is
ready to receive evacuees (patients)
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Ensure that the Operations Section Chief is adequately
supplied with medical forms and charts for receiving
evacuees (patients)
Assist Site Coordinator in developing staffing schedules
for the next 24 hours
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
TASK DESCRIPTION
Participate in shift reviews to assess needs of MNS
Coordinate volunteers
Maintain contact between MNS and
[county/municipality/agency]
Apprise the Site Coordinator of important incoming
information
Provide the Triage Officer with administrative support
staff as needed
Ensure that all supplies and records for designated
areas are handled properly
File and maintain records and completed law
enforcement forms for any security incident occurring
within the MNS, if necessary
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Sign out upon completion of MNS shift
Page 27 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
DEMOBILIZATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Complete a final supplies inventory for the Logistics
Section Chief
Ensure that files and reports are delivered to the
appropriate [county/municipality/agency]
Ensure that any open actions not yet completed will be
handled after demobilization
Remind personnel to clean up areas upon termination
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Participate in and/or complete after-action
requirements
Page 28 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Administrative Support
Job Action Sheet
To provide administrative support for MNS operations.
Reports to: Administrative Section Chief
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Checklist
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Supplies checklist
Contacts list
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in
Put on nametag
Review the job action checklist
Review plans and SOGs
Establish one main entrance for the flow of occupants into
the MNS
Post MNS rules in a visible location at the main entrance
and any exits
Post signs guiding traffic throughout MNS
Page 29 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Work with Logistics Section Chief and facility
safety/security officer(s) to set up security
Provide registration assistance to community shelter,
as needed
Work in specific areas of MNS to provide
administrative support (e.g., triage)
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Maintain situational awareness with the
Administrative Section Chief
Maintain communication among all areas involved
Ensure that incoming and outgoing staff signs in/out
Respond to emergencies in shelter as needed
Assist security officer(s) in locating lost persons
and/or property
Provide all administrative support including copying,
documentation, form completion, filing, etc.
Retain all requisitions, supply lists, purchase orders,
and receipts; all information will be forwarded to the
Management Service Organization for cost recovery
processes
Assist in minor evacuee (patient) care (e.g.,
transport, feeding, etc.), as needed
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Page 30 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Remind personnel to clean up areas upon
termination
Take down any MNS posted materials placed during
activation or response
Organize any requisitions, supply lists, purchase
orders, forms, and receipts
Ensure that any open actions not yet completed will
be handled after demobilization
Participate in staff debriefing, to include mental
health debriefings, if appropriate
Page 31 of 84
Medical Needs Shelter SOG
July 2012
Case Manager
Job Action Sheet
To provide family support and discharge planning.
Reports to: Administrative Section Chief
Required Qualifications: Experience in social work
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
Page 32 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Assist with establishing the evacuee (patient) area,
including a private area for social work
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Maintain situational awareness with the Administrative
Section Chief
Ensure that the needs of the shelter occupants are
being met
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Assist evacuees (patients) with needs as indicated,
obtaining resources and/or referrals to other agencies
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Ensure that evacuee (patient) files and reports are
delivered to the appropriate agency
Through the [county/municipality/agency], assist Site
Coordinator and Operations Section Chief with
transitioning evacuees (patients) from MNS back to
their homes, facilities, or to temporary housing
Ensure that any open actions not yet completed will be
handled after demobilization
Remind personnel to clean up areas upon termination
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Participate in and/or complete after-action
requirements
Page 33 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Operations Section Chief
Job Action Sheet
To ensure appropriate delivery of health/medical services.
Reports to: Site Coordinator
Required Qualifications: Registered Nurse licensed to practice in New Jersey
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
Work with [county/agency] to establish and confirm
medical direction
Communicate with the Site Coordinator when MNS is
ready to receive evacuees (patients)
Page 34 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Ensure that the MNS is adequately supplied with medical
forms and charts for receiving evacuees (patients);
communicate needs with Administrative Section Chief
Anticipate unmet needs and communicate with the
Logistics Section Chief
Coordinate initial medical/health briefing
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Participate in shift reviews to assess needs of MNS
Assess the physical condition of the evacuees (patients)
on an ongoing basis
Maintain the evacuee’s (patient’s) medical update form
Advise the Site Coordinator of any adverse change in
condition of evacuees (patients)
Assess emotional needs of evacuees (patients) and MNS
staff
Monitor the physical environment for safety or
environmental risk
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Monitor those evacuees (patients) receiving oxygen and
refer to respiratory therapist if problems occur
Deliver care and assistance to evacuees (patients) as
required, following approved protocols, procedures, and
guidelines and/or as directed by medical direction
Work with family members/caregivers to assist with
rendering care to the evacuees (patients)
Page 35 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Refer evacuees (patients) who need immediate medical
attention to paramedic and/or contact 911
Maintain standard Universal precautions and infection
control
Coordinate health/medical briefings at the beginning
and end of each shift or while on shift
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Through the [county/municipality/agency], assist Site
Coordinator with transitioning evacuees (patients) from
MNS back to their homes, facilities, or to temporary
housing
Coordinate health/medical debriefing at demobilization
Ensure that evacuee (patient) files and reports are
delivered to the appropriate agency
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Participate in and/or complete after-action
requirements
Page 36 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Triage Officer
Job Action Sheet
To ensure the proper coordination and direction of evacuees (patients) to the MNS.
Reports to: Operations Section Chief
Required Qualifications: Registered Nurse licensed to practice in New Jersey or above
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
List of available resources
Triage guidelines
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
Review triage guidelines
Establish triage area
Coordinate flow with community shelter registration,
if applicable
Page 37 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Participate in initial health/medical briefing
Anticipate administrative needs and request
administrative support, if necessary
Anticipate staffing needs and establish additional
specialty populations triage guidelines with the Site
Coordinator, if necessary
Stock and maintain a sufficient supply of triage forms
RESPONSE –CONTINUING ACTIONS
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Maintain situational awareness with the Operations
Section Chief
Perform all triage functions for MNS evacuees
(patients)
Complete Initial Evaluation Sheet upon evacuee
(patient) arrival
Provide proper identification wristband to evacuees
(patients) upon acceptance into MNS
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Participate in health/medical debriefing at
demobilization
Ensure that any open actions not yet completed will
be handled after demobilization
Remind personnel to clean up areas upon termination
Participate in staff debriefing and conduct mental
health debriefings, if appropriate
Participate in and/or complete after-action
requirements
Page 38 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Registered Nurse
Job Action Sheet
To provide direct evacuee (patient) care in accordance with generally accepted patient care
procedures and protocols.
Report to: Operations Section Chief
Required Qualifications: Registered Nurse licensed to practice in New Jersey
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review plans and SOGs
Review the job action checklist
Work with Licensed Practical Nurse (LPN) to
complete an initial medical supplies check and verify
that the shelter is ready for operation
Communicate with the Operations Section Chief when
MNS is ready to receive evacuees (patients)
Page 39 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Ensure that the MNS is adequately supplied and that all
equipment is set up and in working order
Anticipate unmet needs and communicate with the
Operations Section Chief
Participate in initial medical/health briefing
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Provide appropriate emergency care as needed
Monitor all aspects of evacuee (patient) care, including
diet
Monitor, record, and report symptoms and changes in
evacuees’ (patients') conditions
Record evacuees’ (patients') medical information and
vital signs
Assist and administer evacuee (patient) medications,
including intravenous medications
Modify evacuee (patient) treatment plans as indicated
by evacuees’ (patients') responses and conditions
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Operations Section Chief
Oversee evacuee (patient) care technicians in delivery of
care to evacuees (patients)
Visit evacuees (patients) to ensure that proper care is
provided
Assess the needs of individuals to identify potential
health or safety problems
Provide medical and first aid care to evacuees (patients)
Sign out upon completion of MNS shift
DEMOBILIZATION
Page 40 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
DATE/TIME
TASK DONE
TASK DESCRIPTION
Complete a final supplies inventory for the Logistics
Section Chief
Participate in health/medical debriefing at
demobilization
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Participate in and/or complete after-action
requirements
Page 41 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Licensed Practical Nurse
Job Action Sheet
To provide direct evacuee (patient) care in accordance with generally accepted patient care
procedures and protocols.
Report to: Operations Section Chief
Required Qualifications: Licensed Practical Nurse licensed to practice in New Jersey
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
ASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review plans and SOGs
Review the job action checklist
Work with RN to complete an initial medical supplies check
and verify that the shelter is ready for operation
Communicate with the Operations Section Chief when MNS
is ready to receive evacuees (patients)
Page 42 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Ensure that the MNS is adequately supplied and that all
equipment is set up and in working order
Ensure that battery-operated equipment (e.g., AED) is fully
charged and functional
Anticipate unmet needs and communicate with the
Operations Section Chief
Participate in initial medical/health briefing
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Provide appropriate emergency care as needed
Monitor, record, and report symptoms and changes in
evacuees’ (patients') conditions
Record evacuees’ (patients') medical information and vital
signs
Assist evacuees (patients) with medications
Observe all staff and evacuees (patients) for signs of stress,
fatigue, and inappropriate behavior; report concerns to
Operations Section Chief
Visit evacuees (patients) to ensure that proper care is
provided
Assess the needs of individuals to identify potential health
or safety problems
Provide medical and first aid care to evacuees (patients)
Sign out upon completion of MNS shift
Page 43 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
DEMOBILIZATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Participate in health/medical debriefing at demobilization
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Page 44 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Evacuee (Patient) Care Technician
Job Action Sheet
To provide general assistance to the nursing staff in caring for evacuees (patients).
Report to: Operations Section Chief
Required Qualifications: Certified Nursing Assistant or higher
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
ASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Checklist
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Anticipate unmet needs and communicate with the LPN or
RN
Participate in initial medical/health briefing
RESPONSE – CONTINUING ACTIONS
Page 45 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Assist LPN and RN with taking baseline vital signs as
needed
Regularly disinfect and maintain the MNS, including
changing of bedsheets, proper handling, disinfecting, or
disposal of medical supplies
Assist with evacuee (patient) care such as feeding,
moving, bathing, changing linens, etc.
Observe evacuees’ (patients’) conditions, including food
and liquid intake, and report changes to LPN or RN
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Operations Section Chief
Assist with basic evacuee (patient) comfort needs
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Participate in health/medical debriefing at demobilization
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Page 46 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Pharmacy
Job Action Sheet
To maintain and distribute of medications to evacuees (patients).
Reports to: Operations Section Chief
Required Qualifications: Certified Pharmacist
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Job Action Sheet
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Available medications supply list
Pens/Pencils
Supplies checklist
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Establish a secure pharmacy location for storage of
medication and other supplies
Work with Security Officer to establish secure
pharmacy access
Page 47 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Anticipate unmet needs and communicate with
Logistics Section Chief
Complete an initial medications check and verify that
the shelter is ready for operation with Operations
Section Chief
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Take medication inventory upon receipt of a
medication from a supplier or an evacuee (patient)
Take medication inventory upon issuance from
pharmacy stock or evacuee (patient) individual
medications
Work with Operations Section Chief and Logistics
Sections Chief to maintain adequate medicinal supplies
Coordinate with the Logistics Section Chief and the
Operations Section Chief for special requests
Observe all staff and evacuees (patients) for signs of
stress, fatigue, and inappropriate behavior; report
concerns to Site Coordinator
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Review and organize supply invoices and remaining
supply inventory
Ensure that all medications are accounted for
Coordinate with the RN to ensure that the proper
medication is returned to evacuees (patients)
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Page 48 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Mental Health Counselor
Job Action Sheet
To assess the mental health needs of the evacuees (patients), their caregivers, and staff in the
MNS and provide crisis management or referral.
Reports to: Operations Section Chief
Required Qualifications: Licensed Mental Health Professional
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Checklist
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
List of available resources
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
Assist with establishing the evacuee (patient) area,
including a private area for mental health counseling
RESPONSE – INITIAL ACTIONS
Page 49 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Participate in initial health/medical briefing
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Assist evacuees (patients) with needs as indicated,
obtaining needed resources and referral to other
mental health professionals
Assess evacuees (patients), their caregivers, and staff
for signs of stress or anxiety and provide intervention
as needed
Assist evacuees (patients) with needs as indicated,
obtaining resources and/or referral to other agencies
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Participate in health/medical debriefing at
demobilization
Ensure that evacuee (patient) files and reports are
delivered to the appropriate agency
Ensure that any open actions not yet completed will
be handled after demobilization
Remind personnel to clean up areas upon termination
Participate in staff debriefing and conduct mental
health debriefings, if appropriate
Participate in and/or complete after-action
requirements
Page 50 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Emergency Medical Services Transport Crew
Job Action Sheet
To provide initial lifesaving actions and transportation to and from other health facilities.
Report to: Operations Section Chief
Required Qualifications: EMS-Appropriate Certifications (e.g.. EVOC, EMT (B), etc.)
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
ASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Checklist
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Begin documentation of actions
Sign in with Administrative Support
Put on nametags
Review the job action checklist
Review plans and SOGs
RESPONSE – INITIAL ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
Ensure that the transport vehicle is adequately supplied and
that all equipment is set up and in working order
Ensure that battery-operated equipment (e.g., AED) is fully
charged and functional
Page 51 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Anticipate unmet needs and communicate with the
Operations Section Chief
Participate in initial medical/health briefing
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Maintain contact with local hospitals and acute care sites to
determine transportation to the appropriate healthcare
facility
Provide Basic Life Support/Advanced Life Support (BLS/ALS)
in emergency situations
Transport evacuees (patients) with life-threatening
emergencies to a proper healthcare facility
Assist Evacuee (Patient ) Care Technicians when appropriate
Observe all staff and evacuees (patients) for signs of stress,
fatigue, and inappropriate behavior; report concerns to
Operations Section Chief
Assist with basic evacuee (patient) comfort needs
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Complete a final supplies inventory for the Logistics Section
Chief
Participate in health/medical debriefing at demobilization
Remind personnel to clean up areas upon termination
Ensure that any open actions not yet completed will be
handled after demobilization
Participate in staff debriefing, to include mental health
debriefings, if appropriate
Page 52 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Clergy
Job Action Sheet
To assess the spiritual health needs of the evacuees (patients), their caregivers, and staff in the
MNS and provide crisis management or referral.
Reports to: Operations Section Chief
Required Qualifications: Ordained Clergy Member
NAME:
DATE:
MATERIALS AND INFORMATION INVENTORY
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Job Action Checklist
Copy of [County name] Medical Needs Shelter (MNS)
Standard Operating Guidelines (SOGs)
Relevant reference materials
List of available resources
Pens/Pencils
Communications devices (e.g., phones, radios)
ACTIVATION/NOTIFICATION
DATE/TIME
TASK DONE
TASK DESCRIPTION
Begin documentation of actions
Sign in with Administrative Support
Put on nametag
Review the job action checklist
Review plans and SOGs
Assist with establishing the evacuee (patient) area,
including a private area for spiritual support
counseling
RESPONSE
– INITIAL
Page
53 of 84ACTIONS
Medical Needs Shelter SOG
July 2012
REFERENCE
DATE/TIME
TASK DONE
TASK DESCRIPTION
REFERENCE
Participate in initial health/medical briefing
RESPONSE – CONTINUING ACTIONS
DATE/TIME
TASK DONE
DESCRIPTION
REFERENCE
Assist evacuees (patients) with needs as indicated,
obtaining needed resources and referral to other
mental health professionals
Assess evacuees (patients), their caregivers, and staff
for signs of stress or anxiety and provide support if
indicated
Assist evacuees (patients) with needs as indicated,
obtaining resources and/or referral to other agencies
Work with Case Worker and Mental Health Counselor
to ensure that evacuee (patient) needs are being met
Sign out upon completion of MNS shift
DEMOBILIZATION
DATE/TIME
TASK DONE
DESCRIPTION
Participate in health/medical debriefing at
demobilization
Ensure that any open actions not yet completed will
be handled after demobilization
Remind personnel to clean up areas upon termination
Participate in staff debriefing and conduct mental
health debriefings, if appropriate
Page 54 of 84
Medical Needs Shelter SOG
July 2012
REFERENCE
Appendix 4 – MNS Site Locations
Location
Facility Name
Address
Facility Contact
Location
within
facility
Potential
Capacity3
Primary
Secondary
3
Potential capacity is the total number of MNS beds that could potentially be located in that facility. The standard
MNS cache is 25 beds.
Page 55 of 84
Medical Needs Shelter SOG
July 2012
4.1 – Floor Plans
Page 56 of 84
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July 2012
Appendix 5 – Memorandum of Agreement between [County]
and [Facility Name]
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July 2012
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Page 58 of 84
Medical Needs Shelter SOG
July 2012
Appendix 6 – County Support Service Providers
Service
Organization/Agency
Name
Dietary/Food Service
Sanitation
Durable Medical
Equipment
Pharmacy
Medical Supplies/
Oxygen
Transportation
Security
Page 59 of 84
Medical Needs Shelter SOG
July 2012
Address
Contact
Information
This page intentionally left blank
Page 60 of 84
Medical Needs Shelter SOG
July 2012
Appendix 7 – Supply List
The following list of supplies is based on a need for 25 patients.
Administrative & Office Equipment
Product
Code
Equipment
Descrip.
2 - 3 Hole Punch
UOM
QTY
Each
1
Pack
2
Each
2
Each
2
Box
2
Box
2
Box
2
Clipboards, Metal Box
Each
15
Desk/Table Lamp
Desk/Table Lamp Replacement Bulbs (60 Watt,
4/Pack)
Easel and Dry Erase Board
Each
3
Pack
6
Each
3
Flashlight
Each
2
Highlighter (Flourescent Pink)
Pack
2
Highlighter (Flourescent Yellow)
Pack
3
Labels
Box
1
Labelwriter 310 Label Printer
Each
2
Marker, Dry Erase (Black)
Each
1
Marker, Dry Erase (Red)
Each
1
Marker, Flip Chart (Black)
Each
1
Marker, Flip Chart (Red)
Each
1
Masking Tape (1" x 60 YD)
Each
3
Pad, Lined (Legal)
Dozen
1
2 Pads
CTN
2
100 pgs
Book
1
Box
2
Paper Clips, Jumbo
Box
2
Paper Clips, No. 1
Box
2
Paper, Copy
Carton
2
Pen, Stick Ballpoint (Medium Point)
Dozen
2
Pencil Sharpener, Electric
Each
1
Pencils, Woodcase #2
Dozen
2
Removable Notes (4" x 6")
Dozen
2
Pair
1
Staple Remover
Each
1
Stapler
Each
2
Box
2
8/
2/
2/
12/
12/
12/
Batteries (AA Size) - Rayovac
Batteries (C Size) - Rayovac
Batteries (D Size) - Rayovac
Binder Clips, Large
Binder Clips, Medium
Binder Clips, Small
Pads, Easel
Pads, Telephone Message (2 part)
Paper Clamps, Butterfly Shaped
12/
Scissors
Blunt
Staples
5000/
Page 61 of 84
Medical Needs Shelter SOG
July 2012
Trailer
Location
Tape Dispenser
Each
1
Transparent Tape
Roll
2
Envelopes, #10 Business
500/
Box
1
Envelopes, 32# Kraft Clasped (9" x 12")
500/
CTN
1
UOM
QTY
Each
1
Labels (Allergy)
Housekeeping Equipment
Product
Code
Equipment
Descrip.
Locking Medicine Cabinet (Safe)
Body Lotion
288/
Case
1
Chlorine Bleach, Liquid
4 gal
Case
1
Disinfectant Spray (franklin)
12/
Case
1
Hand Sanitizer
12/
Case
1
1000/
Case
1
12 rolls
Case
1
1000
Case
1
Case
1
UOM
QTY
Tube
Each
1
6/
Paper Cups, 8 oz.
Paper Towels
Sanwich Bags 10 x 14
Facial Tissue, 200/40 packs
Trailer
Location
Medical Equipment and Supplies
Product
Code
Equipment
Descrip.
Antipruritic Ointment
Bag-Valve Mask, Adult
Case
1
Bag-Valve Mask, Child
Each
2
Bag-Valve Mask, Infant
Each
2
Carts for Trailer
Exam Gloves, Extra Large (11", .6 mil Nitrile)
50/
Box
1
Exam Gloves, Large (11", .6 mil Nitrile)
50/
Box
1
Exam Gloves, Medium (11", .6 mil Nitrile)
50/
Box
1
Exam Gloves, Small (11", .6 mil Nitrile)
50/
Box
1
Sharps Containers (2 gallon)
Each
10
AED
Each
1
AED Replacement Defibrillator Pads (6/Box)
Each
2
1" x 10 yds
12 /
Box
1
1/2" x 10 yds
24/
Box
1
6/
Box
2
Pediatric
Each
1
Adult
Each
1
Asst. Size
Each
1
4 Roll/Box
1
3000
Case
1
1 pint
Each
1
2" x 10 yds
Acetominophen (non-aspirin) - Liquid, pediatric
Acetominophen (non-aspirin)
Adhesive Strips
Adhesive Tape
3" x 5"
Alcohol Prep
Alcohol, isopropyl
Page 62 of 84
Medical Needs Shelter SOG
July 2012
Trailer
Location
Ammonia Inhalant - Breakable Capsules
100
Box
1
Antacid, Low Sodium - Alcalak - 50 x 2
100
Box
1
Antibiotic Ointment - Neosporin ointment
1 oz
Tube
1
Bottle
Each
1
6" long
Case
1
Aspirin, 5 grain - Tri-Buffered Aspirin
250
Pkgs
1
Bandage Gauze Roller
12/
Bag
1
Bandage, Self Adhering, 3" x 5 yds - Asst. Colors
24/
Box
1
16/
Box
1
100/
Box
1
Basin, 8 QTS, Disposable
Each
25
Bed Pan, Disposable
Each
25
Bedside Commode with Comfort Grip Armrest
Each
1
Betadine Scrub Solution - 16 oz
Bottle
6
Box
2
Each
1
BP Kit (Adult, Child, Infant, Obese, Thigh) Blue - Kits
Each
1
Bulb Syringe, 2 oz.
Each
3
Calamine Lotion, 4 oz.
Bottle
1
Central Line Kit (Dressing Tray with Tegaderm)
Each
1
Compact Suction Unit
Pkg of 6
1
Compact Suction unit - 800cc
Each
1
Compressor/Nebulizer (Pulmo-Aide)
Each
1
Case
1
Antiseptic, 16 oz.
Applicator - Cotton Tipped - Case of 2000
Bandage, Self Adhering, 6" x 4.1 yds (Non-sterile)
Band-Aids, 3/4" x 3"
Bio-Hazard Infectious Waste Bags, 10 Gallons
Bio-Hazard Waste Container
50/
20 gal
Cotton Balls - Non-sterile, large
2000/
Dressing, 2 x 2
10/
Box
3
Dressing, 4 x 4
10/
Box
4
Elastic Bandage, 3"
10/
Box
1
Emesis Basin, Disposable Kidney Shaped
10/
CTN
3
Package
1
Box
1
Each
6
Each
1
50/
Box
1
2/
Box
1
100/
100
Sheets
16 oz.
Box
1
Box
1
Bottle
1
10/
CTN
1
Insulin Needle & Syringe - 28g x 1/2" 1cc
100/
Box
1
Iodine Swabs
100/
Box
Epipen Auto Injector
2/
Eye Pads
50/
Gauze Compresses, Ind. Wrapped 3 x 3 or 4 x 4
200/pkg
Glucometer (Accu-Check)
Glucometer Strips (Accu-Check)
Active Controls (Accu-Check)
Lancets (Accu-Check)
Handi-Wipes - Bacterial BZK Wipes
Hydrogen Peroxide
Ice Bag
Irrigation Kit
IV Administration Sets, Standard (10 drops)
Page 63 of 84
Medical Needs Shelter SOG
July 2012
50/
Each
1
Case
1
IV Administration Sets, Standard (60 drops)
50/
Case
6/
Pack
1
IV Poles - 2 Hook, Caster
IV Preparation Kit - (IV Started Kit) - with Tegaderm
Dressing
Lantern, Tuff Lite, 4D
Each
1
Each
1
Each
1
Loom Woven Wool Blanket - Blue
Each
25
Box
1
Nasal Cannulas, Adult
Each
1
Nasal Cannulas, Infant/Pediatric
Each
1
Nebulizer Kit, Disposable (Pulmo-Aide)
Each
10
IV Armboard (2" x 9")
Luer Adapter - Multi Sample
100/
Nitriderm Surgical gloves, Non-latex - Size 6.5
25/
Box
1
Nitriderm Surgical gloves, Non-latex - Size 7.5
25/
Box
1
Kit
1
Box
1
Each
1
Box
1
Pocket Mask Replacement One Way Valves
Each
5
Privacy Partitions
Each
2
Pulse Oximeter
Each
1
Pulse Oximeter Charger
Each
1
Box
1
Each
3
Obstetrical Kit
Peak Flow Meter - Disposable Mouth Piece Standard
Peak Flow Meter - Standard Range
100/
Pediatric Band-Aids - Sesame Street
100/
Respirator, N-95 with One-Way Valve
10/
Safety Glasses
Safety Pins Size #1
144
Bag
1
Safety Pins Size #2
144
Bag
1
Safety Pins Size #3
Sensicare Non-Latex Powder Free Exam Gloves Large
Sensicare Non-Latex Powder Free Exam Gloves Medium
Sensicare Non-Latex Powder Free Exam Gloves Small
Sensicare Non-Latex Powder Free Exam Gloves Extra Large
Shears, Paramedic
144
Bag
1
100/
Box
1
100/
Box
1
100/
Box
1
100/
Box
1
Each
1
Case
1
Each
1
Sheets, Disposable
50/
Spill Kit - EZ Clean Spill Kit
Sterile Water - 1000ML
12/
Case
1
Sterile Water - 250ML
12/
Case
1
Sterile Water - 500ML
12/
Case
1
Stethoscopes
Each
5
Stethoscopes - Pediatric
Each
5
Suction Catheter Mini Soft Kits
Each
1
Suction Catheters - 6FR
Each
2
Page 64 of 84
Medical Needs Shelter SOG
July 2012
Suction Catheters - 8FR
Each
2
Suction Catheters - 10FR
Each
2
Suction Catheters - 12FR
Each
2
Suction Catheters - 14FR
Each
2
Suction Catheters - 16FR
Each
2
Suction Catheters - 18FR
Each
2
50/
Box
1
144/
Box
1
Syringe, 30cc (Syringe Only)
40/
Box
1
Syringe, Self-Sheathing, 3cc
100/
Box
1
Syringe, Self-Sheathing, 5cc
100/
Box
1
Syringe, Self-Sheathing, 10cc
100/
Box
1
Tape, 1" x 10 yd (Hypo)
12 Rolls/
Box
1
Tape, 3" x 10 yd (Hypo)
4 Rolls/
Box
1
100/
Box
1
Each
5
Surgical Masks with Face Shields
Surgilube (5 gram packet)
TegadermTransparent Dressing
Thermometer, Digital
Thermometer, Genius - Kendall
Each
1
Throat Lozenges
300/
Bag
1
Tongue Depressors
100/
Box
1
Each
2
Tracheostomy Care Set with Hydrogen Peroxide
Triple Antibiotic Ointment (1 gram)
144/
Box
1
Underpads ("Blue" Pads)
300/
Case
1
Urinal, Male, Disposable
12/
Case
1
Each
2
Urinary Drainage Bag
Wound Care Cleaner Spray
Bottle
1
Wound Dressing (Sorbsan) - 3" x 3"
12 oz.
10/
Box
1
IV Needle, 14g - Catheter
50/
Box
1
IV Needle, 16g - Catheter
50/
Box
1
IV Needle, 18g - Catheter
50/
Box
1
IV Needle, 20g - Catheter
50/
Box
1
IV Needle, 22g - Catheter
50/
Box
1
IV Needle, Butterfly, 25g
50/
Box
1
150/
Box
Lancet (Use with Glucometer)
Needle, 20g x 1-1/2" - for Syringes
1
Needle, 22g x 1-1/2" - for Syringes
1
Needle, 25g x 1" - for Syringes
1
Oxygen Cylinder, E size Aluminium
Each
Oxygen Humidifiers
Case
Oxygen Regulator (Single DISS Connection)
Oxygen Supply Tubing
Suction System with Large Bore Yankauer, Adult
(Res-Q-Vac or equivilent)
Page 65 of 84
Medical Needs Shelter SOG
July 2012
Case
1
Each
1
Suction System Replacement Kits, Adult (includes
Yankauer and Canister)
Suction System, Battery Operated (S-Scort III or
Equivalent)
Syringe (1cc)
Each
1
Each
1
?
Syringe, 30cc
50/
Box
1
Syringe, 60cc
25/
Box
2
Each
8
UOM
QTY
Small
Each
1
Regular
Each
6
Manual
Each
1
Diapers, Adult, Disposable, Med/Large
72
Case
1
Diapers, Baby, Disposable, Med/Large
96/
Case
1
Case
1
Box
1
50/
Case
2
Disposable Pillowcase
100/
Case
1
Disposable Towels - Mauve 2 ply
500/
Case
1
Each
1
Pack
2
Each
1
Thermometer, Digital Probe Covers
Thermometer, Pacifier
Trailer (24 ft L x 8 ft W)
Patient Care Equipment
Product
Code
Equipment
Descrip.
Refrigerator
Sanitary Napkins
Signage
Can Opener
Formula, Infant, Powdered and Liquid
Identification Bracelets
1000/
Disposable Pillow
Walker, Folding
Washcloths, Disposable
50/
Wheelchair
Chair, Folding
CTN
2
Food Tables (Folding Snack Size)
4/
Each
1
Table, Folding 72" x 30"
Each
1
Adult Cots
Each
25
Pads for Cots
Each
25
Child Cots
Each
3
Hand Carts
Each
1
Page 66 of 84
Medical Needs Shelter SOG
July 2012
Trailer
Location
Appendix 8 – Site Forms
Medical Needs Shelter Rules
1. Staff, volunteers, and visitors must sign in at front desk.
2. No firearms, drugs, or alcohol are allowed in this facility.
3. No pets except service pets are allowed.
4. No smoking allowed.
5. You must use the public pay phones. Office phones are for emergency staff
communications.
6. Meals will be served at the following times:
a. Breakfast: ______________________________________________
b. Lunch: _________________________________________________
c. Dinner: _________________________________________________
7. Quiet Hours are _______________ to _________________.
8. Please help keep your area and the facility clean.
9. Please secure your valuables. Shelter staff is not responsible for lost items.
10. If you have any questions or problems, please ask one of the staff members for
assistance.
(PLEASE POST)
MNS FORM 1
Page 67 of 84
Medical Needs Shelter SOG
July 2012
MNS FORM 2
Medical Needs Shelter Registration Record
Patient Name: _______________________
MEDICAL NEEDS SHELTER
REGISTRATION RECORD
Social Security #: _____________________
Shelter Site: _________________________
TO BE COMPLETED BY PATIENT
Arrived via:  Self-Report  Referral (Circle: Hospital or Congregate Shelter)  Local EMS
Date: ______________
Time: ________________
Personal Information:
Patient Name: __________________________
Birth Date:
______/_____/_____
 Male
Sex:  Female
Marital
Status: _____________
Age: ______ Social Security No: _____-______-_____
Ethnicity/Race: _________________________
Religious Preference: ___________________
Address: ____________________________________________________________________
City, State, Zip: _______________________________________________________________
Telephone no: (________) _____________
Work Telephone: (________) ________________
Employed By: ________________________________________________________________
Emergency Contact Information:
Contact Name: _________________________ Telephone No: (________) ________________
Relationship to Patient:__________________ Work Telephone: (________) ________________
Medical Insurance Information:
Insurer
____________
Policy Number
_____________
Policy Holder
_____________
Type of Coverage
Sgl. Fmly. Pri. Sec.

____________
_____________
_____________

Comments:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page 68 of 84
Medical Needs Shelter SOG
July 2012
MNS FORM 3
Medical Needs Shelter Registration Record
Patient Name: _______________________
MEDICAL NEEDS SHELTER
INITIAL TRIAGE SHEET
Social Security #: _____________________
Shelter Site: _________________________
TO BE COMPLETED BY PATIENT
Medical Information:
Date: ___________
Physician: _____________________________
Phone: _____________________________
Pharmacy: ____________________________
Phone: _____________________________
Illnesses:
Anemia
Angina Pectoris
Asthma
Cancer
Depression
Diabetes
Emphysema
Glaucoma
Heart Disease
High Blood Pressure
Kidney/Bladder Problems
Lung Disease, Tuberculosis
Mental Illness
Mumps, Measles, Chicken Pox
Seizure Disorder/Epilepsy
Stroke
Thyroid Disease
_____________________
_____________________
_____________________
_____________________
Medications: (Include Prescription and Over the Counter)
Medication Name
Amount
Frequency
Allergies:
Allergy
Amount
Frequency
With You?
Page 69 of 84
Medical Needs Shelter SOG
July 2012
With You?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
MNS FORM 3
Medical Needs Shelter Registration Record
CONTINUED FROM FIRST PAGE
Treatments: (i.e. Blood Sugar, Wound Care, etc.)
Treatment
Type
Frequency
Special Conditions: (Check all that apply)
 Insulin Dependent
 Language Barrier
 Special Dietary Needs
 Incontinence
 Wheelchair Bound
 Walker/Cane
 Oxygen Dependent
(Circle: Ventilator, Nasal
Cannula, CPAP)
IV Therapy
Medication Assistance
Catheter (Type:________________ )
Feeding Tube
Wound Care
Memory Impaired
 Mental Health Impaired
 Pediatrics

 Speech Impaired
 Sight Impaired
 Hearing Impaired
Discharge Issues
Mobile Home/Trailer
Medically Dependent on
Electricity

NOTES:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page 70 of 84
Medical Needs Shelter SOG
July 2012
Medical Needs Shelter
Initial Triage Sheet
TO BE COMPLETED BY TRIAGE OFFICER
Time: _____________
Vital Signs:
Pulse: _______
RR: _______
BP: ______
Temperature: ______
Medications Reviewed
Health History Reviewed
Comments
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Other Information:
Caregiver Present (Name and Relationship): ________________________________________
Durable Medical Equipment (List): ________________________________________________
Personal Valuables (List): _______________________________________________________
Accepted by Area Representative
Signature ____________________________________ Date: _______________ Time: _____________
Disposition:
MNS Shelter
Hospital
Community Shelter
Page 71 of 84
Medical Needs Shelter SOG
July 2012
MNS FORM 4
Medical Needs Shelter Medical Update
Patient Name: _______________________
MEDICAL NEEDS SHELTER
MEDICAL UPDATE
Social Security #: _____________________
Shelter Site: _________________________
A signature must accompany all entries.
Observations/Notes
Date/Time
Use progress notes sheet for
additional info
Medications/Treatments
Given
Page 72 of 84
Medical Needs Shelter SOG
July 2012
Signature/Title
MNS FORM 5
Medical Needs Shelter Progress Notes
Patient Name: _______________________
MEDICAL NEEDS SHELTER
PROGRESS NOTES
Social Security #: _____________________
Shelter Site: _________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page 73 of 84
Medical Needs Shelter SOG
July 2012
MNS FORM 6
Medical Needs Shelter Patient Log
Patient Log
Patient Name
MNS FORM 7
Date of
Birth
Location Prior to
Admission
Please specify address or
facility name
Medical Needs Shelter Daily Staff Sign-In Sheet
Page 74 of 84
Medical Needs Shelter SOG
July 2012
Arrival
Date and
Time
Discharge
Date and Time
Discharge to
Daily Staff Sign-In Sheet
Name
Day Shift
Time
Title
In
Out
Total
Hours
Name
Night Shift
Page 75 of 84
Medical Needs Shelter SOG
July 2012
Date: _____/_____/_____
Time
Title
In
Out
Total
Hours
MNS FORM 8
Medical Needs Shelter Visitor Log
Visitor Log
Name
Person Visiting
Page 76 of 84
Medical Needs Shelter SOG
July 2012
Date
Time In
Time Out
MNS FORM 9
Medical Needs Shelter Pharmacy Inventory
Medical Needs Shelter
Patient Name
Medication/Equipment
Page 77 of 84
Medical Needs Shelter SOG
July 2012
Notes/Comments
(Dosage, Special Instructions, etc.)
MNS FORM 10
Pre-activation Facility Inspection
Date: ______________
Time: ______________
Facility Name: __________________________________________________________________________
Facility Address: ________________________________________________________________________
Facility Representative: ___________________________________________________________________
MNS Site Coordinator: ___________________________________________________________________
MNS Administrative Section Chief:__________________________________________________________
The condition of the Medical Needs Shelter (MNS) facility will be thoroughly documented utilizing this
form and digital photographs of existing damage. Photographs will be annotated using the room
number and the specific area-corresponding letter to pinpoint the condition of the facility prior to
activation of the MNS. Each room or corridor, regardless of condition, should have at least one digital
photo of the interior. This photo may be used during the demobilization inspection to serve as a general
comparison between pre-activation and demobilization. In addition to interior conditions, a thorough
examination of the exterior of the facility (walls, doors, windows, etc.) should be documented, if
applicable.
Examples of conditions that should be documented include but are not limited to the following:










Cracks
Divots
Staining
Mold
Dirt
Broken appliances (e.g., light fixtures)
Scuffing
Leaks
Broken windows, doors, etc.
Holes
Upon inspection of each room, please check the OK box or describe any problems and document them
with a digital photograph. Each inspection sheet should be signed by the Facility Representative, MNS
Site Coordinator, and MNS Administrative Section Chief.
Page 78 of 84
Medical Needs Shelter SOG
July 2012
Room #____________
Date Inspected: ______________
Name/Description of the Room:
_____________________________________________________________________________
A. General Cleanliness
OK
____________________________________________________________________________________
____________________________________________________________________________________
B. Floor/Carpet:
OK
____________________________________________________________________________________
____________________________________________________________________________________
C. Walls:
OK
____________________________________________________________________________________
____________________________________________________________________________________
D. Ceiling:
OK
____________________________________________________________________________________
____________________________________________________________________________________
E. Window(s):
OK
____________________________________________________________________________________
____________________________________________________________________________________
F. Door(s):
OK
____________________________________________________________________________________
____________________________________________________________________________________
G. Other (appliances, outlets, etc.):
OK
____________________________________________________________________________________
Please sign: _____________________
______________________
_________________________
____________________________________________________________________________________
Facility Representative
MNS Site Coordinator
MNS Administrative Chief
Page 79 of 84
Medical Needs Shelter SOG
July 2012
MNS FORM 11
Demobilization Facility Inspection
Date: ______________
Time: ______________
Facility Name: __________________________________________________________________________
Facility Address: ________________________________________________________________________
Facility Representative: ___________________________________________________________________
MNS Site Coordinator: ___________________________________________________________________
MNS Administrative Section Chief: _________________________________________________________
The condition of the Medical Needs Shelter (MNS) facility will be thoroughly documented utilizing this
form and digital photographs of demobilization damage. Photographs will be annotated using the room
number, and the specific area-corresponding letter to pinpoint the condition of the facility upon
demobilization of the MNS. Each room or corridor, regardless of condition, should have at least one
digital photo of the interior. This photo was taken during the pre-activation facility inspection and
should serve as a general comparison between pre-activation and demobilization. In addition to interior
conditions, a thorough examination of the exterior of the facility (walls, doors, windows, etc.) should be
documented, if applicable.
Examples of conditions that should be documented include but are not limited to the following:
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Cracks
Divots
Staining
Mold
Dirt
Broken appliances (e.g., light fixtures)
Scuffing
Leaks
Broken windows, doors, etc.
Holes
Upon inspection of each room, please check the OK box or describe any problems and document them
with a digital photograph. Each inspection sheet should be signed by the Facility Representative, MNS
Site Coordinator, and MNS Administrative Section Chief.
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July 2012
Room #____________
Date Inspected: ______________
Name/Description of the Room:
_____________________________________________________________________________
OK
A. General Cleanliness
____________________________________________________________________________________
____________________________________________________________________________________
OK
B. Floor/Carpet:
____________________________________________________________________________________
____________________________________________________________________________________
OK
C. Walls:
____________________________________________________________________________________
____________________________________________________________________________________
OK
D. Ceiling:
____________________________________________________________________________________
____________________________________________________________________________________
OK
E. Window(s):
____________________________________________________________________________________
____________________________________________________________________________________
OK
F. Door(s):
____________________________________________________________________________________
____________________________________________________________________________________
G. Other (appliances, outlets, etc.):
OK
____________________________________________________________________________________
____________________________________________________________________________________
Please sign: _____________________
Facility Representative
______________________
MNS Site Coordinator
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July 2012
_________________________
MNS Administrative Chief.
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July 2012
Appendix 9 – Waivers
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Appendix 10 – Sample Media Release
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Medical Needs Shelter SOG
July 2012