ML20077E286

Rev 28 to Procedure/Work Plan 1903.023, Personnel Emergency

ML20077E286
Person / Time
Site:	Arkansas Nuclear
Issue date:	11/28/1994
From:	ENTERGY OPERATIONS, INC.
To:
References
1903.023, NUDOCS 9412120222
Download: ML20077E286 (17)

Text

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ENTERGY OPERATIONS INCORPORATED ARKANSAS NUCLEAR ONE Arkansas Nuclear One Russellville, Arkansas Date: 941205 MEMORANDUM TO: 103 *Please return transmittal CC - NRC - WASHINGTON to Document Control, 3RD floor Admin Bldg

• FROM: DOCUMENT CONTROL Ref Key: 17378

SUBJECT:

PLANT MANUAL UPDATE: NEW REVISION TO PROCEDURE PROCEDURE / FORM NUMBER: OP-1903.023 REV. # 28 TC # 0 PC # 1 PROCEDURE / FORM TITLE: PERSONNEL EMERGENCY The following pages of the indicated procedure (s) contains items which involve personal privacy or proprietary material. PLEASE REMOVE THE INDICATED MATERIAL PRIOR TO DISTRIBUTION TO PUBLIC DOCUMENT ROOMS, ETC.

PROCEDURE (S) PAGE(S)

SIGNATURE: DATE:

UPDATED PRINT NAME form title: form no. rev.

TRANSMITTAL (PROCEDURE / WORK PLANS / CHANGES / FORMS) 1013.002H ond' z-t ', sJ' 14 u 9412120222 941128 hi PDR F

ADOCK 05000313 PDR . /hh./(cl

g ENTERGY OPERATIONS INCORPORATED

===ENTERGY ARKANSAS NUCLEAR ONE 63 of 79 O TiTte: PEReo~~ ele eRee~Cv c'*o '~~-

1903.023 ev.

28 EXP.DATE SAFETY-RELATED IES ONO CONTROLLED COPY # /03 PAoE , og , y,S PAGE REV CHG PAGE REV CHG PAGE REV CHG PAGE REV CHG 1 28 2 28 3 (28 4 28 5 28 6 28 7 28 8 28 9 28 10 28 VERIFIED BY DATE TIME 11 28 12 28 l l

13 28 14 28 l

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APPROVAL AUTHORITY: APPROVAL DATE: )

/h26- 44 REQUIRED EFFECTIVE DATE: 4l $y FORM TITLE:[ FORM NO. REV.

[ LIST OF AFFECTED PAGES 1000.006A 41 j 1

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1.0 PURPOSE The purpose of this procedure is to. provide for the proper response to a personnel emergency. Guidance is provided for general ANO personnel, operations Personnel, ANO Emergency Medical Team Personnel and Health Physics Personnel.

2.0 SCOPE' This procedure outlines the general response to be taken during a personnel

-emergency. The emergency may be medical or contamination related medical and may require that offsite medical assistance be utilized. This procedure is not intended to give medical guidance for use during the emergency.

3.1 REFERENCES

USED IN PROCEDURE PREPARATION:

3.1.1 Emergency Plan 3.1.2 1012.019, " Radiological Work Permits" 3.1.3 Red Cross First Aid Instruction Pamphlets

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3.1.4 NCRP Report No. 39, " Basic Radiation Protection Criteria" l 1

3.1.5 NCRP Report No. 65, " Management of Persons Accidentally l Contaminated with Radionuclides" j

{

t 3.1.6 10CFR50.72 (b) (2) (v)

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3.2 REFERENCES

USED IN CONJUNCTION WITH THIS PROCEDURE:

. k' 3.2.1 1012.023, " Personnel Contamination Events" (PCE) 3.2.2 1903.033, " Protective Action Guidelines for Rescue / Repair and Damage control Teams" 3.2.3 1905.001, " Emergency Radiological Controls" 3.2.4 1000.104, " Condition Reporting and Corrective Action" 3.2.5 1000.031, " Radiation Protection Manual" l 3.2.6 Station Directive A6.202, "Public Communications" 3.2.7 Emergency Telephone Directory 3.3 RELATED ANO PROCEDURES:

3.3.1 1903.042, " Duties of the Emergency Medical Team" 3.3.2 ANO Station Policy S, " Work Accident Reporting and Medical Referrals" g 3.3.3 ANO Station Policy U, " Arkansas Nuclear One Industrial Safety Program"

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~ 1093.023 PERSONNEL EMERGENCY _

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3.4 REGULATORY CORRESPONDENCE CONTAINING NRC COMMITMENTS WHICH ARE IMPLEMENTED IN THIS PROCEDURE INCLUDE:

3.4.1 Letter OCAN108213, Appendix A, Item 1 A. Section 7.2.2 3.4.2 Letter OCAN058411 A. Section 8.2.2 3.4.3 Letter OCAN068320 A. 1903.023B, Step 7.0 4.0 DEFINITIONS 4.1 ANO Medical /HP Personnel - Shift Health Physics (HP) personnel have been trained to serve as medical team members. Shift HP personnel will serve as sole medical team members during non-routine working hours, with non-HP and HP personnel serving on the team during regular working hours. Upon declaration of an Alert and activation of the Emergency Response Organization, the volunteer medical team will be assembled to augment the medical team members present at that time.

4.2 A serious injury that requires action specified in this procedure is frg defined as an injury to any person that has resulted in one or more of the following:

( j 4.1.1 More than a momentary loss of consciousness.

4.1.2 An actual or suspected fracture.

4.1.3 A head injury.

4.1.4 An injury that may have damaged internal organs.

4.1.5 A serious burn.

4.1.6 Hemorrhaging.

4.1.7 Receipt of a large dose of radiation (i.e., greater than 50 R) .

4.3 Protected Area - An area encompassed by physical barriers (i.e., the security fence) and to which access is controlled.

5.0 RESPONSIBILITY AND AUTHORITY 5.1 ANO Dmployees'- as described in Section 8.1 of this procedure.

5.2 shift Superintendent 5.2.1 Responsible for ensuring that ANO medical /HP Personnel are activated and dispatched to the scene of a medical emergency (Also dispatch additional HP Personnel, if needed, for radiological concerns).

5.2.2 Responsible for coordinating offsite medical assistance.

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\, / 5.2.3 Responsible for declaring Emergency Class as appropriate.

5.3 Operational Support Center Director 5.3.1 May relieve the Shift Superintendent of responsibility for steps 5.2.1 and 5.2.2 above.

5.4 Emergency Medical Team - as described in procedure 1903.042, " Duties of_the Emergency Medical Team".

5.5 ANO Nurse - as described in procedure 1903.042,

• Duties of the Emergency Medical Team".

5.6 Health Physics Personnel 5.6.1 Responsible for augmenting the daytime Dmergency Medical Team during routine working hours and staffing the Emergency Medical Team during non-routine working hours.

5.6.2 Responsible for determining the level of contamination, if involved, as stated in Section 8.4.

5.6.3 Responsible for ensuring personnel are surveyed prior to exiting the protected area (see Section 8. 5) .

5.6.4 Responsible for monitoring dose rates and time in Radiologically Controlled Areas.

5.6.5 Responsible for acting as the RWP if time did not permit Emergency Medical Team members to read and sign in on an RWP prior to entering a Radiologically Controlled Area.

6.0 LIMITS AND PRECAUTIONS 6.1 Personnel administering first aid to an injured person in a suspected or undefined radiation field should be joined by a Health Physics representative (in addition to any HP's on the Emergency Medical Team, if needed) with the appropriate radiation monitoring equipment as soon as possible.

6.2 Entry into evacuated or high radiation areas for the purpose of attending to injured or contaminated individuals shall be in accordance with 1903.033, " Protective Action Guidelines-for Rescue / Repair and Damage Control Teams".

6.3 If it is not clear that the individual can be moved without harm, he should not be moved until further help arrives, unless the individual would be in danger of loss of life or limb or is in a life threatening radiation field. If questions arise, contact the Health Physics Supervisor or the Shift Superintendent.

6.4 Individuals who have suffered any of the conditions described in 1 Section 4.0 should receive a medical examination prior to returning to work.

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-d 7.0 FIRST AID SUPPLIES AND EQUIPMENT 7.1 FIRST AID SUPPLIES ARE MAINTAINED IN THE FOLLOWING LOCATIONS:

A. Unit 1 Turbine Building, Elev. 354 South (Medical Locker A)

B. Unit 2 Turbine Building, Elev. 354 North (Medical Locker B)

C. Unit 1/2 Turbine Building, Elev. 386 (Medical Locker C)

D. Nurse's Station E. CA-1, inside of Controlled Access.

F. CA-3 7.2 To assist St. Mary's Hospital in the treatment of radiologically contaminated individuals, ANO will maintain an emergency kit at St.

Mary's Hospital for use in these situations.

7.3 Equipment or supplies may be provided to assist ambulance personnel.

8.0 INSTRUCTIONS 8.1 ANO PERSONNEL

/'~% In the event of a personnel emergency, personnel in the

(,) 8.1.1 vicinity of the affected individual snould:

l NOTE l DO NOT move the injured individual, unless the individual is in I danger of loss of life or limb or is in a known high radiation field A. Notify either unit's Shift Superintendent and provide the following information:

1 e Location in plant and number of injured people. I e Type of injury.

• Radiation / contamination involved.

• Names of injured individual (s) and employer, if known.

B. Administer immediate first aid and attention within the limits received in training. This attention should consist of but is not limited to the following:

• Stopping bleeding by applying pressure.

() e Using resuscitation techniques if known.

e Keeping the individual calm and comfortable until further help arrives.

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-1093.023 PERSONNEL EMERGENCY CHANGE:

C. Remain available at the scene of the accident to t provide information to the appropriate medical personnel.

8.2 OPERATIONS PERSONNEL 8.2.1 For minor and/or non-emergency situations, Operations personnel should direct any requests for medical attention to the ANO Nurse in the Nurse's Station. If the ANO nurse is not available, treatment of minor injuries (nicks, cuts, etc) should be determined by the individual and his/her supervisor.

8.2.2 The Shift Superintendent shall direct appropriate medical assistance to the seriously injured individual per the following announcement:

I NOTE The plant page should be used to direct medical personnel to the location of the injured person. The Shift Superintendent (or his designee) shall make the l following announcement several times.:

" ATTENTION ALL PERSONNEL! A PERSONNEL EMERGENCY HAS OCCURRED (give location). EMERGENCY MEDICAL TEAM PLEASE RESPOND."

V 8.2.3 For serious personnel emergencies, the Shift Superintendent, or his designee, shall complete Form 1903.023B, " Personnel Emergency Checklist".

8.2.4 If onsite, the ANO Nurse will respond in conjunction with the Emergency Medical Team.

8.2.5 The Shift Superintendent, or his designee, shall make arrangements for treatment based upon the assessment of the-emergency medical personnel at the scene. The following guidance is provided (refer to the Emergency Telephone Directory for telephone numbers):

A. Ambulance Needed Onsite If the injured individual (s) requires immediate attention from a doctor and is judged capable of travel, the Pope County Emergency Medical Service  ;

shall be called, advised of the physical and radiological condition of the injured individual (s) and requested to come immediately to ANO. IF CONTAMINATION IS INVOLVED, A HEALTH PHYSICS REPRESENTATIVE SHALL IMMEDIATELY BE DISPATCHED TO THE EMERGENCY ENTRANCE AT ST. MARY'S HOSPITAL TO ASSIST THE HOSPITAL STAFF AS THE SITUATION WARRANTS.

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m B. Physician Needed Onsite Immediately If the individual (s) has an injury that requires attention by a physician prior to transport (e.g., leg or arm trapped in a pump or victim impaled on an object) and the plant physician cannot be contacted, a physician should be called from Occupational Medical Consults (OMC) and requested to come immediately to ANO. St. Mary's Hospital may be contacted to page a physician if necessary. Pope County Emergency Medical Service shall also be contacted per Step 8.2.5.A.

C. Doctor Not Needed Immediately If the injured individual (s) do not require immediate attention from a doctor and is judged capable of travel, arrangements should be made to transport the  !

individual (s) for further examination to St. Mary's Hospital.

D. Guidance on Excessive Radiation Dose If the injured individual or individual (s) attending to the injured individual are suspected of having received a radiation dose in excess of 50 Rem (TEDE),

l arrangements should be made between the initial attending physician and ANO Management (Vice t

President, Operations - ANO or Shift

\-- Superintendent /TSC Director / EOF Director) to transport those individuals to the University of Arkansas Medical Sciences Hospital in Little Rock for treatment, as necessary, after examination at St.

Mary's Hospital.

8.2.6 If the injured individual will be transported to a medical facility, the Shift Superintendent or OSC Director shall call the appropriate medical facility and advise them of the number of individuals involved, whether or not contamination is involved and the nature of the injuries.

• St. Mary's Hospital (include the appropriate action level - refer to Step 8.4.2)

• University of Arkansas Medical Sciences Hospital 8.2.7 If an ambulance has been requested to come onsite, the Security Shift Commander shall be notified so that Security personnel will be ready to receive and escort the ambulance personnel. (Routine ambulance access point - North Gates routine ambulance receiving area - Maintenance Facility Breezeway unless otherwise directed.) The Security escort shall ensure that the victim's security badge remains onsite.

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O- 8.2.8 An escort, as indicated below, should accompany the injured individual (s) to an offsite hospital in order to provide

, any necessary information or assistance to the offsite medical personnel and provide periodic updates to the Shift' .

Superintendent (or other individual (s), as directed).

A. If the individual is contaminated, a Health Physics representative shall accompany in the ambulance.

B. If the individual is not contaminated, one of the following individuals should accompany:

1. ANO Medical Team Member

2. ANO Nurse

3. ANO Industrial Safety Coordinator

4. An ANO Management Representative

5. Any knowledgeable member of the ANO plant staff.

8.2.9 A Notification of Unusual Event Emergency Class shall be declared by the Shift Superintendent when a medical emergency requires transporting a radiologically contaminated individual from the site to an of f-site medical facility. (Reference procedure 1903.010, O 8.2.10

" Emergency Action Level Classification".)

The injured employee's supervisor should respond in accordance with Station Admin. Procedure 1000.128

" Industrial Safety and Occupational Health".

8.3 Emergency Medical Personnel NOTE During a " Personnel Emergency" the Emergency Medical Team may '

go into Radiologically Controlled Areas without SRDs/ Alarming Dosimeters as long as an HP Technician is acting as the RWP; and is monitoring dose rates and time in the area. Prompt medical attention shall take precedence over HP procedures.when l an individual is seriously injured.

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8.3.1 Emergency Medical Personnel should respond per procedure j 4 1903.042, " Duties of the Emergency Medical Team" (section 1 6.3 lists medical response instructions). l 8.4 Health Physics Personnel (If radiation / contamination is known or suspected)

NOTE Medical attention and transportation to an offsite medical facility takes precedence over decontamination measures for seriously injured individual (s).

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O- 8.4.1 If the injured individual is contaminated and will require

(~~'/ - transport to the hospital, a Health Physics Technician shall IMMEDIATELY be dispatched to the emergency room at St. Mary's Hospital to assist the hospital staff in

. preparing-to receive a contaminated patient. The HP should report to the licensed nurse on duty in the emergency room.

8.4.2 The following action levels for St. Mary's Hospital shall be referenced and provided to the Shift Superintendent or the OSC Director.

Level of St. Mary's Action Response for Levels Contamination Control A. LEVEL I No Detectable None Counts above background as measured by a Frisker B. LEVEL II Any detectable Routine sterile procedures counts above for septic situations background -

1000 counts per minute above background as

[-~s' '

measured by a Frisker C. LEVEL III >1000 counts per Full-scale response minute above background as measured by a Frisker 8.4.3 The following precautionary measures should be taken at the scene of the accident (as allowed by the nature of the injury):

A. Take precautions (coverings, use of stretcher, etc.)

to prevent the spread of contamination during movement and transport of the individual.

B. Move the individual to a " clean" area, as allowed by step 6.3.

C. Remove cor.taminated clothing.

D. Survey the individual for surface contandnation.

E. Decontaminate the affected areas removing as much transferable contamination as possible per- 1012.023,

" Personnel Contamination Events" (PCE).

F. Cover remaining areas.

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)' 8.4.4 If the situation requires an ambulance and Pope County Emergency Medical Service personnel must enter a potentially contaminated area, the following assistance  !

should be provided by' Health Physics personnel: j NOTE I Prompt medical attention shall take precedence over HP procedures when an individual is seriously injured.

A. Assist in dressing out. ,

B. Provide dosimetry devices (these may be obtained from the Control Room emergency kit if necessary) .

C. Provide a brief description of radiological' conditions ,

they will encounter during the response. l D. Provide special information to perform the task.

E. Bag equipment - (to reduce chances of contamination) .

F. Provide HP escort.

G. Assist in exiting the controlled Access Axea (to include any necessary decontamination).

8.4.5 A Health Physics representative, in addition to the one dispatched to St. Mary's Hospital per Step 8.4.1, shall accompany an injured and contaminated patient both onsite and to offsite medical facilities. This HP should:

A. Remain with the victim from the scene of the accident to the emergency room and provide " volunteered" advice and assistance to Pope County Emergency Medical .

Service personnel and St._ Mary's emergency personnel concerning proper radiological controls.

B. Attempt to answer any questions the attending physician may have concerning the victim.

C. After decontamination efforts are complete at the hospital, remove the injured person's TLD for further dose determination and coordinate as necessary with 'I dosimetry and radwaste.  !

The HP that assisted the hospital staff in the set-up of I 8.4.6 the emergency room shall ensure that the ambulance and l ambulance attendants are surveyed after the victim (s) has H been transported into the emergency room. l 8.4.7 Both of the HP's at the hospital should provide assistance and offer advice-concerning the clean-up and decontamination of the facilities and equipment.

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• Pact 10 of15 1093.023 PERSONNEL EMERGENCY e 28 CHANGO 8.5 Health Physics Personnel (If radiation / contamination is not suspected) 8.5.1 If a personnel injury occurs within the protected area and contamination is not suspected, Health Physics personnel-shall ensure that the individual is surveyed prior to exiting the site.

8.5.2 Personnel leaving the protected area will normally exit through a portal monitor. If a portal monitor and/or frisker is not available at an exit point from the protected area, Health Physics shall provide a portal-monitor or frisker for the period of time that the exit is open.

9.0 REPORTING AND RECORDS MANAGEMENT 9.1 Follow-up and reporting (written) of the personnel injury or accident should be accomplished as stated in ANO Station Policy S ' Work Accident Reperting and Medical Referrals" and ANO Station Policy U "ANO Industrial Safety Program".

9.2 The three-part carbonless Form 1903.023A should be distributed in the following manner:

9.2.1 Forward the white copy to the Emergency Planning Supervisor 9.2.2 Ensure that the. yellow copy accompanies the victim offsite 9.2.3 Forward the pink copy to the ANO Nurse 9.3 Form 1903.023B should be forwarded to the Emergency Planning Supervisor.

9.4 Form 1903.023C should be forwarded to the Emergency Planning Supervisor.

10.0 ATTACHMENTS AND FORMS 10.1 Form 1903.023A " Personnel Injury" 10.2 Form 1903.023B

• Personnel Emergency Checklist" 10.3 Form 1903.023C

• Emergency Medical Team Scene Leader Check List" w

11 cf 15 NAME OF INJURED PERSON COMPANY DATE/. TIME OF INJURY / BADGE DESCRIPTION OF OCCURRENCE:

- INJURIES NOTED:

MEDICAL TEAM TREATMENT:

O s- MEDICAL PERSONNEL RESPONDING VITAL SIGNS Time B/P Pulse i Resp.

Dosimeter Reading Action Level: Check Appropriate Space Notify Shift Superintendent /OSC Director of

( ) Level 1 no detectable counts action level. If transported to hospital, above BKG the HP escort is responsible for reporting

( ) Level 2 any detectable counts decontamination levels. For contamination above BKG-1000 CPM levels and decontamination records, refer above BKG to HP Procedure 1012.023, " Personnel

( ) Level 3 >1000 epm above BKG Contamination Events".

FORM COMPLETED BY DATE/ TIME DISTRIBUTION: (White - Emergency Planning) (Yellow - Patient) (Pink - ANO Medical)

FORM NO. REV.

FORM TITLE:

1903.023A 28 PERSONNEL INJURY

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% NOTE Emergency telephone numbers are contained in the Emergency Telephone Directory Initials 1.0 Activate the Emergency Medical Team as follows:

1.1 Activate the Fire / Medical tone.

1.2 Make the following announcement on the plant public address system:

" Attention all personnel, attention all personne11 A personnel emnergency has occurred (GIVE LOCATION).

Emergency Medical Team respond."

2.0 Notify the ANO Medical Department of the medical emergency (Ext. 3250).

3.0 Dispatch an HP to the scene.

4.0 Dispatch an Operator to the scene with a handheld radio.

5.0 Verify that the base radio console is selected to channel 1 with the scrambler on.

l I 6.0 Repeat step 1.0.

7.0 IF an ambulance is needed, THEN:

7.1 Gather available information:

7.1.1 Number of injured personnel:

7.1.2 Nature of injuries:

7.1.3 Contamination level (check appropriate box): l l

1 0 Level 1 (No detectable counts above background)

O Level 2 (Any detectable counts above backgroand - 1000 pm above background) l 0 Level 3 (>1000 cpm above background) l 7.2 Notify the Pope County Dmergency Medical Service (use a GTE direct telephone line and dial 911) and provide 1 them with the information in 7.1.

7.3 Notify St. Mary's Hospital Room (968-6211) and I provide them with the information in 7.1.

7.4 Notify Security (3383) that an ambulance is responding to the site.

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PERSONNEL EMERGENCY CHECKLIST 1903.023B 28

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{ g 8.0 ' Repeat Step 1.0.

9.0 IF contamination is known or suspected AND injured personnel are to be transported offsite, THEN perform the following:

9.1 Dispatch at least one HP immediately to the hospital.

9.2 Verify that one HP (in addition to the one above) accompanies the patient onsite and to the hospital.

9.3 Notify the HP supervisor to ensure that onsite HP staffing needs are met.

9.4 Notify the plant physician.

QR IF unable to contact the plant physician, THEN have St. Mary's Emergency Room (968-6211) staff notify a j physician from Occupational Medical Consultants. )

l NOTE  ;

Transport of a contaminated and injured person to an offsite medical facility I meets the criteria for a Notification of Unusual Event in accordance with l procedure 1903.010, EAL 9.1.

{ l 10.0 IF injured personnel are transported to the hospital, THEN notify the following persons:

• General Manager, Plant Operations (if not available, notify the Duty EOF Director)

• Supervisor of injured person 11.0 IF the circumstances surrounding the injury warrant, THEN initiate a Condition Report in accordance with procedure 1000.104," Condition Reporting and Corrective Action".

Signed: Date:

(Shift Superintendent /OSC Director)

• When complete, Forward this form to the Emergency Planning Supervisor

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FORM NO, REV.

PERSONNEL EMERGENCY CHECKLIST 1903.023B 28

14cf15 j'%

i EMERGENCY MEDICAL TEAM SCENE LEADER CHECKLIST Page 1 of 2 CALL OUT RESPONSE Complete the following checklist and forward to the Supervisor, Emergency Planning upon completion.

Verify scene safe.

Perform Primary Survey.

Iastgn patient care responsibilities bppoint communicator. Name Appoint an H.P. to perform radiological controls. Name Assign one team member to complete form 1903.023A. Name Confirm if ambulance is needed on-site.

Verify that Control Room has requested an ambulance. Time Confirm doctor required at this location

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(' Have Communicator provide Control Room

• Name and badge number of patient information from Form 1903.023A.

• Nature of injuries

• Patient's employer

• Patient' supervisor (if patient is contaminated)

• Level of contamination (if known)

• General area dose rates (if known)

Request H.P. to the scene if none have arrived. Name Assign a security officer to clear the area if necessary Name If the patient is contaminated and stable, Check which steps were .

perform the followings performed (li5) )

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a. If the scene is safe, decon patient at  ;

scene. j

b. Move patient to CA-1 for i decontamination

c. Decon as time permits while waiting on the ambulance i

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EMERGENCY MEDICAL TEAM SCENE LEADER CHECKUST 1903.023C 28

15 of 15 Page 2 of 2 l I Assign an ENT/HP to drape ambulance with herculite if transporting a contaminated injured patient to the hospital Name _

Ensure that the patient's TLD and SRD stay with the patient if contaminated.

Direct Security Officer to take possession of patient's security badge. Name Notify the Radwaste Supervisor for transportation of radioactive material from the hospital back to ANO Name Assign EMT members to restore Medical Kits to service, and complete Kit inventory form. Name Notify Control Room or OSC that patient has left ANO enroute to Hospital, and that Personnel Time Emergency is terminated. Notified Confirm plant status with Control Normal Conditions Room or OSC. NUE Alert Site Area Emergency General Emergency As soon as possible provide Shift Superintendent or OSC Director with detail of incident.

NARRATIVE

SUMMARY

OF INCIDENT RESPONSE: l l

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I Signature Date When complete, forward this form to the Supervisor, Emergency Planning.

FORM TITLE: FORM NO. REV.

EMERGENCY MEDICAL TEAM SCENE LEADER CHECKLIST 1903.023C 28