HICS-213 – INCIDENT MESSAGE FORM

1. FROM (Sender):
:1:

2. TO (Receiver):
:2:

3. DATE RECEIVED

4. TIME RECEIVED

5. RECEIVED VIA

6. REPLY REQUESTED:

:3:

:4:

If NO, REPLY TO: :6c:

7. PRIORITY

:7a:

Urgent - High

:7b:

Non Urgent – Medium

:7c:

Informational - Low

8. MESSAGE (KEEP ALL MESSAGES / REQUESTS BRIEF, TO THE POINT, AND VERY SPECIFIC):

:8:

9. ACTION TAKEN (if any):

:9:

Received by:

Time Recveived:

Forward to:

:10:

:11:

:12:

Comments:

:13:

Received by:

Time Recveived:

Forward to:

:14:

:15:

:16:

Comments:

 :17:

10. FACILITY NAME
:18: