Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصحة‬

Directorate of Health Affairs-Najran ‫ نجران‬- ‫مديرية الشؤون الصحية‬
Maternity & Children’s Hospital ‫مستشفى الوالدة واألط‬
Disaster Management

Patient Evacuation Tracking Log

PATIENTS CATEGORY EQUIPMENT MODE OF DATE & TIME RECEIVING ARRIVAL AT
(use transport NEEDS TRANSPORTATION PATIENT FACILITY & DESTINATION
barcode label) LEFT PHYSICIAN
UNIT
□ Red □ Oxygen Ambulatory Date:_________ ____________ Time:____
(significant □ Monitor □ Wheelchair Time:_________ Destination ____________
resources for □ Ventilator □ Stretcher ______________ ____________ Contact Name
transport) □ Pump □ Bassinet Staff Initials Equip. Lv ______________
□ Yellow □ Other (indicate) □ Isolette w/Patient Staff Initials
(moderate ______________ □ Other (indicate) ____________
resources for _ __________________ Receiving
transport) ______________ __________________ Physician
□ Green _
(minimal ______________
resources _
□ Red □ Oxygen Ambulatory Date:_________ ____________ Time:____
(significant □ Monitor □ Wheelchair Time:_________ Destination ____________
resources for □ Ventilator □ Stretcher ______________ ____________ Contact Name
transport) □ Pump □ Bassinet Staff Initials Equip. Lv ______________
□ Yellow □ Other (indicate) □ Isolette w/Patient Staff Initials
(moderate ______________ □ Other (indicate) ____________
resources for _ __________________ Receiving
transport) ______________ __________________ Physician
□ Green _
(minimal ______________
resources _
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Directorate of Health Affairs-Najran ‫ نجران‬- ‫مديرية الشؤون الصحية‬
Maternity & Children’s Hospital ‫مستشفى الوالدة واألط‬
Disaster Management

VISITOR EVACUATION TRACKING TEMPLATE

Visitor Name and Patient Visiting Time Left Unit Destination Arrival at Destination
Telephone
Contact Number
□ Yes
□ No
Initials: _________
□ Yes
□ No
Initials: _________
□ Yes
□ No
Initials: _________
□ Yes
□ No
Initials: _________
□ Yes
□ No
Initials: _________
□ Yes
□ No
Initials: _________
□ Yes
□ No
Initials: _________