Hospital Name and Location: Date:
Rooms Capacity In Use Available
1 Adult ICU
2 Adult Medical/Surgical
3 Burn Unit
4 PICU(Pediatric ICU)
5 Pediatrics Medical/Surgical
6 Maternity(OB)
7 Psychiatric-Adult
8 Psychiatric-Pediatric
9 Psychiatric-Substance Abuse
10 Negative Pressure/Isolation
11 Ventilator
12 Operating Rooms
13 Triage Tag- Green
14 Triage Tag- Yellow
13 Triage Tag- Red