California Amateur Radio Service -- Emergency Incident Worksheet

Attachment 2

EMERGENCY INCIDENT WORKSHEET

(California Amateur Radio Service)

WE OPERATE AS THOUGH ALL COMMERCIAL POWER IS OFF.

PART A:

1. DATE: ________________ TIME: __________________ FREQUENCY: ____________________________

2. NATURE OF EMERGENCY: _______________________________________________________________

_________________________________________________________________________________________

3. LOCATION OF EMERGENCY: ____________________________________________________________

4. CONTACT PERSON/CALL: _______________________________________________________________

5. SPECIAL CONDITIONS (e.g., Chemical, Explosives, Poisons, Children, Elderly, etc.):

___________________________________________________________________________________________

PART B:

1. REQUEST FOR ASSISTANCE (Medical, Law Enforcement, Rescue, Evacuation, Supplies, other):

___________________________________________________________________________________________

2. PERSON MAKING REQUEST (Name, Telephone Number, etc.):

___________________________________________________________________________________________

PART C:

1. AGENCY, PERSON CONTACTED, LOCATION: ______________________________________________

2. WHAT REQUEST WAS MADE? ____________________________________________________________

3. ACTION TAKEN BY AGENCY/PERSON: _____________________________________________________

4. OTHER CONTACTS/REQUESTS: ___________________________________________________________

5. TIME COMPLETED: ______________________________

AMATEUR RADIO OPERATOR:

NAME: ________________________________________________________CALL: ____________________

DATE: _____________ TIME: ____________

COMMENTS:

_________________________________________________________________________________________

PLEASE FORWARD A COPY TO:

David L. Wilner, WA6YOC
P.O. Box 2340
Novato, CA 94948-2340