July 14, 2016
MEDICAL PLAN
ICS 206
1. INCIDENT/EVENT NAME 2. OPERATIONAL PERIOD
From (Date and Time):
To (Date and Time):
3. MEDICAL AID STATIONS
Contact With Paramedics? Remarks
Name Location Contact Person
Number(s) Yes No
4. AMBULANCE/ MEDICAL TRANSPORTATION SERVICES
Contact Level of Service Remarks
Name Location Contact Person
Number(s) BLS ALS
5. HOSPITALS
With With With
Contact Contact Travel Time Trauma Burn Helipad?
Name Location Center? Center?
Person Number(s)
Air Land Yes No Yes No Yes No
6. MEDICAL EMERGENCY PROCEDURES
__ Check if aviation assets are utilized for rescue. If assets are used, coordinate with Air Operations Branch.
7. Prepared by MEDL Name and Signature: Date Prepared: Time Prepared:
8. Reviewed by SOFR Name and Signature: Date Reviewed: Time Reviewed:
July 14, 2016
ICS 206: MEDICAL PLAN
PURPOSE: The ICS 206 provides information on incident medical aid stations, transportation
services, hospitals, and medical procedures primarily intended for the responders.
PREPARATION: The ICS 206 is prepared by the Medical Unit Leader (MEDL) and reviewed by
the Safety Officer (SOFR).
DISTRIBUTION: The ICS 206 is duplicated and attached to the ICS 202 and given to all
recipients as part of the Incident Action Plan (IAP). All completed original forms must be given
to the Documentation Unit.
HOW TO FILL-UP THE FORM:
BLOCK NO. BLOCK TITLE INSTRUCTIONS
1 Incident/Event Name Enter the name assigned to the incident/event
2 Operational Period Enter the start date (mm-dd-yyyy) and time (24 hour format)
and end date and time for the operational period to which
the form applies.
3 Medical Aid Stations Enter the relevant information on the incident/field medical
aid station(s). Indicate the name, location, contact person
and contact number(s). Also specify whether or not
paramedics are provided.
4 Ambulance/Medical Enter the relevant information on the ambulance/medical
Transportation transportation service(s). Indicate the name, location,
Services contact person and contact number(s). Also specify the
level of service if Basic Life Support (BLS) or Advance Life
Support (ALS).
5 Hospitals Enter the relevant information on the hospital(s). Indicate
the name, location, contact person and contact number(s).
Also specify the travel time going to the hospital. Further,
indicate if there are trauma center, burn center, and/or
helipad.
6 Medical Emergency Enter any special emergency instructions for use by
Procedures incident personnel including (1) who should be contacted,
(2) how should they be contacted, and (3) who manages an
incident within an incident due to a rescue, accident, etc.
Include procedures for reporting medical emergencies.
7 Prepared by MEDL Enter complete name of the MEDL, signature, date (mm-
dd-yyyy), and time (24 hour format) the form was prepared
and completed.
8 Reviewed by SOFR Enter complete name of the SOFR, signature, date (mm-
dd-yyyy), and time (24 hour format) the form was reviewed.
July 14, 2016
MEDICAL PLAN
ICS 206
1. INCIDENT/EVENT NAME 2. OPERATIONAL PERIOD
Rizal Earthquake From (Date and Time): 09-17-20xx, 1000H
To (Date and Time): 09-17-20xx, 2200H
3. MEDICAL AID STATIONS
Contact With Paramedics? Remarks
Name Location Contact Person
Number(s) Yes No
Dr National
Bo. Kalaklan Jericho Royalista 12345 /
Station 1
4. AMBULANCE/ MEDICAL TRANSPORTATION SERVICES
Contact Level of Service Remarks
Name Location Contact Person
Number(s) BLS ALS
AMB – 1 Bo. Barretto Peter Piper 45678 /
5. HOSPITALS
With With With
Contact Contact Travel Time Trauma Burn Helipad?
Name Location Center? Center?
Person Number(s)
Air Land Yes No Yes No Yes No
St. Jude Dr. Maja 20
Bo. Subic 98765 / / /
Hospital Salvadore mins
6. MEDICAL EMERGENCY PROCEDURES
__ Check if aviation assets are utilized for rescue. If assets are used, coordinate with Air Operations Branch.
Name and Signature:
Date Prepared: Time Prepared:
7. Prepared by MEDL Gu
09-16-20xx 1500H
Gu Jun Pyo
Name and Signature:
Date Reviewed : Time Reviewed:
8. Reviewed by SOFR Kathryn
09-16-20xx 1700H
Kathryn Bernardo
