ICS Form 201

1. Incident Name 2. Date Prepared 3. Time Prepared

INCIDENT BRIEFING OPLAN KALULUWA OCT. 30, 2019 0800H

4. Map Sketch

4. Prepared by (Name and Position)

ICS 201 PLANNING SECTION CHIEF
Page 1 of 4
 6. Summary of Current Actions

FULL IMPLEMENTATION OF INCIDENT COMMAND SYSTEM (ICS) ALREADY PUT IN PLACE ATER THE
PLAN WAS APPROVED ON MDDRMC CONDUCTED FOR THE PURPOSE. THE FOLLOWING AREAS OF
CONCERN CONSIDERED:

LAND:

WASAR:

MOSAR:

ICS 201 Page 2

 7. Current Organization

ICS 201 Page 3

 8. Resources
Summary
Resources Ordered Resource Identification ETA On Location/Assignment
Scene
LCE EOC

MDRRMO EOC

COP EOC

FIRE MARSHALL EOC

IC ICP

SOFR ICP

LOFR ICP

PIO ICP

OSC ICP

PSC ICP

LSC ICP

VEHICULAR ICP
EXTRICATION GROUP
VE T1 TEAM LEADER STAGING AREA 1

VE T2 TEAM LEADER STAGING AREA 1

VE T3 TEAM LEADER STAGING AREA 4

VE T4 TEAM LEADER STAGING AREA 5

WASAR GROUP SUP. STAGING AREA 3

WASAR TF1 TEAM ROVING/STAGING AREA 2

LEADER
WASAR TF2 TEAM ROVING
LEADER
MOSAR GROUP SUP STAGING AREA 4
ICS 201 Page 4
 ICS Form 202

1. INCIDENT NAME 2. DATE 3. TIME

INCIDENT OBJECTIVES

4. OPERATIONAL PERIOD (DATE/TIME)

5. GENERAL CONTROL OBJECTIVES FOR THE INCIDENT (INCLUDE ALTERNATIVES)

6. WEATHER FORECAST FOR OPERATIONAL PERIOD

7. GENERAL SAFETY MESSAGE

8. Attachments (inif attached)

Organization List (ICS 203) Medical Plan (ICS 206) Weather Forecast
Assignment List (ICS 204) Incident Map
Communications Plan (ICS 205) Traffic Plan

9. PREPARED BY (PLANNING SECTION CHIEF) 10. APPROVED BY (INCIDENT COMMANDER)

 Organization Assignment List, ICS Form 203

1. INCIDENT NAME 2. DATE PREPARED 3. TIME PREPARED

ORGANIZATION ASSIGMENT LIST
POSITION NAME 4. OPERATIONAL PERIOD (DATE/TIME)

5. INCIDENT COMMAND AND STAFF 9. OPERATIONS SECTION

INCIDENT COMMANDER CHIEF
DEPUTY DEPUTY
SAFETY OFFICER a. BRANCH I-
DIVISION/GROUPS INFORMATION OFFICER BRANCH
DIRECTOR
LIAISON OFFICER DEPUTY
DIVISION/GROUP
6. AGENCY REPRESENTATIVES DIVISION/ GROUP
AGENCY NAME DIVISION/ GROUP
DIVISION/GROUP
DIVISION /GROUP

b. BRANCH II- DIVISIONS/GROUPS

BRANCH DIRECTOR
DEPUTY
DIVISION/GROUP
7. PLANNING SECTION DIVISION/GROUP
CHIEF D IVISION/GROUP
DEPUTY D IVISION/GROUP
RESOURCES UNIT
SITUATION UNIT c. BRANCH III-
DIVISIONS/GROUPS
DOCUMENTATION UNIT BRANCH
DIRECTOR DEMOBILIZATION UNIT DEPUTY
TECHNICAL SPECIALISTS
DIVISION/GROUP
DIVISION/GROUP
DIVISION/GROUP

8. LOGISTICS SECTION d. AIR OPERATIONS

BRANCH CHIEF AIR OPERATIONS
BR. DIR. DEPUTY AIR TACTICAL
GROUP SUP.
AIR SUPPORT GROUP SUP.
HELICOPTER COORDINATOR
a. SUPPORT BRANCH AIR TANKER/FIXED WING CRD.
DIRECTOR
SUPPLY UNIT
FACILITIES UNIT
GROUND SUPPORT UNIT 10. FINANCE/ADMINISTRATION SECTION
CHIEF
DEPUTY
b. SERVICE BRANCH TIME UNIT
DIRECTOR PROCUREMENT UNIT
COMMUNICATIONS UNIT COMPENSATION/CLAIMS UNIT
MEDICAL UNIT COST UNIT
FOOD UNIT
PREPARED BY (RESOURCES UNIT)
 Sample Assignment List, ICS Form 204

1. BRANCH 2. DIVISION/GROUP
ASSIGNMENT LIST
3. INCIDENT NAME 4. OPERATIONAL PERIOD
DATE TIME

5. OPERATIONAL PERSONNEL
OPERATIONS CHIEF DIVISION/GROUP SUPERVISOR
BRANCH DIRECTOR AIR TACTICAL GROUP SUPERVISOR

6. RESOURCES ASSIGNED TO THIS PERIOD

DROP
NUMBER TRANS. PICKUP OFF
STRIKE TEAM/TASK FORCE/
PERSONS NEEDED PT./TIME PT./TIME
RESOURCE DESIGNATOR EMT LEADER

7. CONTROL OPERATIONS

8. SPECIAL INSTRUCTIONS

9. DIVISION/GROUP COMMUNICATIONS SUMMARY

FUNCTION FREQ. SYSTEM CHAN. FUNCTION FREQ. SYSTEM CHAN.

LOCAL LOCAL
COMMAND SUPPORT
REPEAT REPEAT

DIV./GROUP GROUND
TACTICAL TO AIR
PREPARED BY (RESOURCE UNIT LEADER) APPROVED BY (PLANNING SECT. CH.) DATE TIME
 Sample Incident Communications Plan, ICS Form 205

1. Incident Name 2. Date/Time Prepared 3. Operational Period

Date/Time
INCIDENT RADIO COMMUNICATIONS PLAN

4. Basic Radio Channel Utilization

System/Cache Channel Function Frequency/Tone Assignment Remarks

5. Prepared by (Communications Unit)

 1. Incident Name 2. Date Prepared 3. Time Prepared 4. Operational Period
MEDICAL PLAN

5. Incident Medical Aid Station

Paramedics
Medical Aid Stations Location
Yes No

6. Transportation
A. Ambulance Services
Paramedics
Name Address Phone
Yes No

B. Incident Ambulances
Paramedics
Name Location
Yes No

7. Hospitals
Travel Time Helipad Burn Center
Name Address Phone
Air Ground Yes No Yes No

8. Medical Emergency Procedures

Prepared by (Medical Unit Leader) 10. Reviewed by (Safety Officer)

ICS 206
 Incident Commander

Safety Of ficer
Incident Nam e
Operational Period
Liaison O fficer or Agency Representative
__________________________ Date
Informat ion O fficer ______________ Time ______________

Operations S ection Finance Sect ion Chief

Chief Planning S ection Logistics S ection Chief
Chief

St aging A rea Manager

Communications Unit Supply Unit Leader

Branch Director Branch Leader
Director Air Operations Resources Unit
Director Leader

Time Unit Leader

Medical Unit
Facilities Unit Leader
Leader
Division/Group S upervisor Division/Group S Air Support S Air At tack Situation Unit
upervisor upervisor Supervisor Leader

Procurement Unit Leader

Food Unit Ground Support Unit Leader
Leader
Division/Group S upervisor Division/Group S Helibase Manager Helicopter Coordinat Demobilizat ion Unit
upervisor or Leader

Comp/ Claims Unit Leader

Security Unit
Leader
Division/Group S upervisor Division/Group S Helispot Manager Document ation Unit
upervisor Air Tanker Coordinat Leader
or
Cost Unit Leader

Fixed Wing B ase Coordinator

Division/Group S upervisor Division/Group S Technical S
upervisor pecialists

Division/Group S upervisor Division/Group S

upervisor
ICS 207 NFES 1332
 INCIDENT STATUS SUMMARY (ICS 209)
*1. Incident Name: 2. Incident Number:
*3. Report Version (check *4. Incident Commander(s) & 5. Incident *6. Incident Start Date/Time:
one box on left): Agency or Organization: Management Date:
☐ Initial Rpt # Organization:
Time:
☐ Update (if used):
Time Zone:
☐ Final

7. Current Incident Size 8. Percent (%) *9. Incident 10. Incident *11. For Time Period:
or Area Involved (use unit Contained Definition: Complexity
Level: From Date/Time:
label – e.g., “sq mi,” “city
block”): Completed To Date/Time:

Approval & Routing Information

*12. Prepared By: *13. Date/Time Submitted
Print Name: ICS Position: Time Zone:
Date/Time Prepared:

*14. Approved By: *15. Primary Location, Organization, or

Agency Sent To:
Print Name: ICS Position:
Signature:

Incident Location Information

*16. State: *17. County/Parish/Borough: *18. City:

19. Unit or Other: *20. Incident Jurisdiction: 21. Incident Location Ownership
(if different than jurisdiction):

22. Longitude (indicate format): 23. US National Grid Reference: 24. Legal Description (township, section,
range):
Latitude (indicate format):

*25. Short Location or Area Description (list all affected areas or a reference point): 26. UTM Coordinates:

27. Note any electronic geospatial data included or attached (indicate data format, content, and collection time information
and labels):

Incident Summary
*28. Significant Events for the Time Period Reported (summarize significant progress made, evacuations, incident growth, etc.):

29. Primary Materials or Hazards Involved (hazardous chemicals, fuel types, infectious agents, radiation, etc.):

30. Damage Assessment Information (summarize A. Structural B. # Threatened C. # D. #

damage and/or restriction of use or availability to Summary (72 hrs) Damaged Destroyed
residential or commercial property, natural E. Single Residences
resources, critical infrastructure and key resources,
etc.): F. Nonresidential
Commercial Property
Other Minor
Structures
Other

ICS 209, Page 1 of * Required when applicable.

 INCIDENT STATUS SUMMARY (ICS 209)
*1. Incident Name: 2. Incident Number:
Additional Incident Decision Support Information
A. # This A. # This
Reporting B. Total # Reporting B. Total #
*31. Public Status Summary: Period to Date *32. Responder Status Summary: Period to Date
C. Indicate Number of Civilians (Public) Below: C. Indicate Number of Responders Below:
D. Fatalities D. Fatalities
E. With Injuries/Illness E. With Injuries/Illness
F. Trapped/In Need of Rescue F. Trapped/In Need of Rescue
G. Missing (note if estimated) G. Missing
H. Evacuated (note if estimated) H. Sheltering in Place
I. Sheltering in Place (note if estimated) I. Have Received Immunizations
J. In Temporary Shelters (note if est.) J. Require Immunizations
K. Have Received Mass Immunizations K. In Quarantine
L. Require Immunizations (note if est.)
M. In Quarantine
N. Total # Civilians (Public) Affected: N. Total # Responders Affected:
33. Life, Safety, and Health Status/Threat Remarks: *34. Life, Safety, and Health Threat
Management: A. Check if Active
A. No Likely Threat ☐
B. Potential Future Threat ☐
C. Mass Notifications in Progress ☐
D. Mass Notifications Completed ☐
E. No Evacuation(s) Imminent ☐
F. Planning for Evacuation ☐
G. Planning for Shelter-in-Place ☐
35. Weather Concerns (synopsis of current and predicted H. Evacuation(s) in Progress ☐
weather; discuss related factors that may cause concern): I. Shelter-in-Place in Progress ☐
J. Repopulation in Progress ☐
K. Mass Immunization in Progress ☐
L. Mass Immunization Complete ☐
M. Quarantine in Progress ☐
N. Area Restriction in Effect ☐
☐
☐
☐
☐

36. Projected Incident Activity, Potential, Movement, Escalation, or Spread and influencing factors during the next
operational period and in 12-, 24-, 48-, and 72-hour timeframes:
12 hours:
24 hours:

48 hours:

72 hours:

Anticipated after 72 hours:

37. Strategic Objectives (define planned end-state for incident):

ICS 209, Page 2 of * Required when applicable.

 INCIDENT STATUS SUMMARY (ICS 209)
*1. Incident Name: 2. Incident Number:
Additional Incident Decision Support Information (continued)
38. Current Incident Threat Summary and Risk Information in 12-, 24-, 48-, and 72-hour timeframes and beyond.
Summarize primary incident threats to life, property, communities and community stability, residences, health care facilities, other
critical infrastructure and key resources, commercial facilities, natural and environmental resources, cultural resources, and
continuity of operations and/or business. Identify corresponding incident-related potential economic or cascading impacts.
12 hours:

24 hours:

48 hours:

72 hours:

Anticipated after 72 hours:

39. Critical Resource Needs in 12-, 24-, 48-, and 72-hour timeframes and beyond to meet critical incident objectives. List
resource category, kind, and/or type, and amount needed, in priority order:
12 hours:

24 hours:

48 hours:

72 hours:

Anticipated after 72 hours:

40. Strategic Discussion: Explain the relation of overall strategy, constraints, and current available information to:
1) critical resource needs identified above,
2) the Incident Action Plan and management objectives and targets,
3) anticipated results.
Explain major problems and concerns such as operational challenges, incident management problems, and
social, political, economic, or environmental concerns or impacts.

41. Planned Actions for Next Operational Period:

42. Projected Final Incident Size/Area (use unit label – e.g., “sq mi”):
43. Anticipated Incident Management Completion Date:
44. Projected Significant Resource Demobilization Start Date:
45. Estimated Incident Costs to Date:
46. Projected Final Incident Cost Estimate:
47. Remarks (or continuation of any blocks above – list block number in notation):

ICS 209, Page 3 of * Required when applicable.

 INCIDENT STATUS SUMMARY (ICS 209)
1. Incident Name: 2. Incident Number:
Incident Resource Commitment Summary

Additio
Person
50.
49. Resources (summarize resources by category, kind, and/or type; show #

nal
of resources on top ½ of box, show # of personnel associated with resource on

notnel
51. Total
bottom ½ of box): Personnel

48. Agency or
Organization:

52. Total Resources

53. Additional Cooperating and Assisting Organizations Not Listed Above:

ICS 209, Page of * Required when applicable.

DESIGNATOR
NAME/ ID. NO.

STATUS I
0ASSIGNED 0AVAILABLE 00/S REST
Do1s MECHANICAL 00/S MANNING
ETR (0/S= Out of Service)

FROM LOCATION TO

DIVISION/GROUP

STAGING AREA

BASE/ICP

CAMP

EN ROUTE

ETA HOME AGENCY

MESSAGES

RESTAT

TIME PROCESSD

ICS STATUS CHANGE CARD

FORM
210 6/83 NFES 1334
 ICS Form 211

INCIDENT CHECK-IN LIST 1. Incident Name 2. Check-In Location (complete all that apply) 3. Date/Time

Check one: Base Camp Staging Area ICP Restat Helibase

Personnel Handcrew Misc.
Engines Dozers
Helicopters Aircraft

Check-In Information
4. List Personnel (overhead) by Agency & Name -OR- 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 16. 16.
List equipment by the following format:
Order/Request Date/ Time Manifest Crew or Departure Point Method of Incident Sent to
Agency Single Kind Type I.D. No/Name

17. Prepared by (Name and Position) Use back for remarks or comments
Page of
 ICS 213

GENERAL MESSAGE
TO: POSITION:

FROM: POSITION:

SUBJECT: DATE: TIME:

MESSAGE:

SIGNATURE: POSITION:

REPLY:

DATE: TIME: SIGNATURE/POSITION:

 1. Incident Name 2. Date Prepared 3. Time Prepared
UNIT LOG
4. Unit Name/Designators 5. Unit Leader (Name and Position) 6. Operational Period

7. Personnel Roster Assigned

Name ICS Position Home Base

8. Activity Log
Time Major Events

9. Prepared by (Name and Position)

ICS 214
 ICS Form 215

1. Incident Name 2. Date Prepared 3. Operational Period (Date/Time)

Time Prepared
OPERATIONAL PLANNING WORKSHEET

4. 5. Resource by Type 6. 7.
Division/Group or Work Assignments (Show Strike Team as ST) Reporting Location Requested
Other Location Arrival Time

Req

Have

Need

Req

Have

Need

Req

Have

Need

9. Req
Total Resources - Single
Have

Need

Req
Prepared by (Name and Position)

Total Resources - Strike Teams Have

Need
 Incident Action Plan Safety & Risk Analysis Form, ICS 215A

INCIDENT ACTION PLAN SAFETY 1. Incident Name 2. Date 3. Time

ANALYSIS

Division or Group Potential Hazards Mitigations (e.g., PPE, buddy system, escape routes)

Type of Hazard:

Type of Hazard:
Type of Hazard:

Type of Hazard:

Type of Hazard:

Type of Hazard:

Type of Hazard:

Type of Hazard:

Prepared by (Name and Position)

 1. Incident Name 2. Date 3. Time
RADIO REQUIREMENTS
4.
WORKSHEET
Branch 6. Operational Period
5. Agency 7. Tactical Frequency

8. Division/Group Division/Group Division/Group Division/Group

Agency Agency Agency Agency

9. Agency ID No. Radio Requirements Agency ID No. Radio Requirements Agency ID No. Radio Requirements Agency ID No. Radio Requirements

10. Prepared by (Name and Position)

Page 1 of

ICS 216
NFES 1339
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 SUPPORT VEHICLE 1. Incident Name 2. Date Prepared 3. Time Prepared
INVENTORY
(Use separate sheet for each vehicle
Vehicle Category: Buses Dozers Engines Lowboys Pickups/Sedans Tenders
Other
Vehicle/Equipment
Resource Order No.
Information Vehicle License
“E” Number Incident ID No. Vehicle Type Vehicle Make Capacity Size Agency/Owner Rig Number Location Release Time

5. Prepared by (Ground Support Unit)

Page of

SUPPORT VEHICLE 1. Incident Name 2. Date Prepared 3. Time Prepared

INVENTORY
(Use separate sheet for each vehicle

ICS 218
NFES 1341
 Vehicle Category: Buses Dozers Engines Lowboys Pickups/Sedans Tenders
Other
Vehicle/Equipment
Resource Order No.
Information Vehicle License
“E” Number Incident ID No. Vehicle Type Vehicle Make Capacity Size Agency/Owner Rig Number Location Release Time

5. Prepared by (Ground Support Unit)

Page of

ICS 218
NFES 1341
 GREEN CARD STOCK (CREW)

AGENCY ST KIND TYPE I.D. NO. AGENCY TF KIND TYPE I.D. NO./NAME

ORDER/REQUEST NO. DATE/TIME CHECK IN INCIDENT LOCATION

TIME

STATUS
HOME BASE ASSIGNED O/S REST O/S PERS.

AVAILABLE
O/S MECH ETR

NOTE
DEPARTURE POINT

INCIDENT LOCATION
TIME
LEADER NAME

STATUS
CREW ID NO./NAME (FOR STRIKE TEAMS) ASSIGNED O/S REST O/S PERS.

AVAILABLE
O/S MECH ETR

NOTE

INCIDENT LOCATION
TIME

STATUS
NO. PERSONNEL MANIFEST WEIGHT
ASSIGNED O/S REST O/S PERS.

YES NO
AVAILABLE
O/S MECH ETR

METHOD OF TRAVEL NOTE

OWN BUS AIR

OTHER INCIDENT LOCATION

TIME

DESTINATION POINT ETA

STATUS
ASSIGNED O/S REST O/S PERS.

TRANSPORTATION NEEDS AVAILABLE

O/S MECH ETR

OWN BUS AIR

NOTE

OTHER

ORDERED DATE/TIME CONFIRMED DATE/TIME

*U.S. GPO: 1990-794-001

REMARKS

ICS 219-2 (Rev. 4/82) CREW NFES 1344

 BLUE CARD STOCK (HELICOPTER)

AGENCY ST KIND TYPE I.D. NO. TYPE MANUFACTURER I.D. NO.

AGENCY

ORDER/REQUEST NO. DATE/TIME CHECK IN

INCIDENT LOCATION TIME

HOME BASE

STATUS
ASSIGNED O/S REST O/S PERS.

AVAILABLE O/S MECH ETR

DEPARTURE POINT

NOTE

PILOT NAME

INCIDENT LOCATION TIME

DESTINATION POINT ETA

STATUS
ASSIGNED O/S REST O/S PERS.

REMARKS
AVAILABLE O/S MECH ETR

NOTE

INCIDENT LOCATION

INCIDENT LOCATION TIME

STATUS
ASSIGNED O/S REST O/S PERS.
STATUS
AVAILABLE O/S MECH ETR ASSIGNED O/S REST O/S PERS.

NOTE AVAILABLE O/S MECH ETR

NOTE
INCIDENT LOCATION TIME

INCIDENT LOCATION
TIME

STATUS
ASSIGNED STATUS
O/S REST O/S PERS.
ASSIGNED O/S REST O/S PERS.
AVAILABLE
O/S MECH ETR
NOTE AVAILABLE O/S MECH ETR

NOTE

ICS 219-4 (Rev. 4/82) HELICOPTER NFES 1346

*U.S. GPO: 1988-594-771 NFES 1346
 ORANGE CARD STOCK (AIRCRAFT)

AGENCY TYPE MANUFACTURER I.D. NO. TYPE MANUFACTURER I.D. NO.

AGENCY
NAME/NO.

ORDER/REQUEST NO. DATE/TIME CHECK IN

INCIDENT LOCATION TIME

HOME BASE

STATUS
ASSIGNED O/S REST O/S PERS.

DATE TIME RELEASED

AVAILABLE O/S MECH ETR

NOTE
INCIDENT LOCATION
TIME

INCIDENT LOCATION
TIME

STATUS
ASSIGNED O/S REST O/S PERS.
STATUS
AVAILABLE O/S MECH ETR ASSIGNED O/S REST O/S PERS.

NOTE

NOTE
INCIDENT LOCATION
TIME

INCIDENT LOCATION
TIME

STATUS
ASSIGNED O/S REST O/S PERS.

AVAILABLE O/S MECH ETR

STATUS
ASSIGNED O/S REST O/S PERS.
NOTE
AVAILABLE O/S MECH ETR

NOTE
INCIDENT LOCATION TIME

INCIDENT LOCATION TIME

STATUS
ASSIGNED O/S REST O/S PERS.

AVAILABLE O/S MECH ETR

STATUS
NOTE
ASSIGNED O/S REST O/S PERS.

AVAILABLE O/S MECH ETR

NOTE

ICS 219-6 (4/82) AIRCRAFT

*U.S. GPO: 695-162-1986 NFES 1348
 YELLOW CARD STOCK (DOZERS)

AGENCY ST TF KIND TYPE I.D. NO. ST TF KIND TYPE I.D. NO.

AGENCY

ORDER/REQUEST NO. DATE/TIME CHECK IN

INCIDENT LOCATION TIME

HOME BASE

STATUS
ASSIGNED O/S REST O/S PERS.

DEPARTURE POINT

NOTE

LEADER NAME
INCIDENT LOCATION
TIME

RESOURCE ID. NO.S/NAMES

STATUS
ASSIGNED O/S REST O/S PERS.

AVAILABLE
O/S MECH ETR

NOTE

DESTINATION POINT
ETA

INCIDENT LOCATION TIME

REMARKS

STATUS
ASSIGNED O/S REST O/S PERS.

AVAILABLE O/S MECH ETR

NOTE
INCIDENT LOCATION TIME

INCIDENT LOCATION
TIME

STATUS
ASSIGNED O/S REST O/S PERS.

AVAILABLE
O/S MECH ETR STATUS

NOTE ASSIGNED O/S REST O/S PERS.

AVAILABLE O/S MECH ETR

NOTE

ICS 219-7 (Rev. 4/82) DOZERS NFES 1349

*U.S. GPO: 1990-794-006
 1. Incident Name Helibases
AIR OPERATIONS SUMMARY
Fixed Wing Bases

4. Personnel and Communications Name Air/Air Frequency Air/Ground Frequency 5. Remarks (Spec. Instructions, Safety Notes, Hazards, Priorities)
Air Operations

Director Air Attack

Supervisor Helicopter

Coordinator

Air Tanker Coordinator

6. Location/Function 7. Assignment 8. Fixed Wing 9. Helicopters 10. Time 11. Aircraft 12. Operating
No. Type No. Type Available Commence Assigned Base

13. Totals

14. Air Operations Support Equipment 15. Prepared by (include Date and Time)

ICS 220
NFES 1351
 DEMOBILIZATION
CHECKOUT
1. Incident Name/Number 2. Date/Time 3. Demob. No.

4. Unit/Personnel Released

5. Transportation Type/No.

6. Actual Release Date/Time

7. Manifest? Yes No Number

8. Destination 9. Notified: Agency Region Area

Dispatch

Name:

Date:
10. Unit Leader Responsible for Collecting Performance Rating

11.
You and your resources have been released subjectUnit/Personnel
to sign off from the following:
Demob. Unit Leader check the appropriate box
Logistics Section

Supply Unit

Communications

Unit Facilities Unit

Ground Support Unit Leader

Planning Section

Documentation Unit

Finance Section

Time Unit

Other

12. Remarks

DEMOBILIZATION
CHECKOUT
1. Incident Name/Number 2. Date/Time 3. Demob. No.

4. Unit/Personnel Released

5. Transportation Type/No.

ICS 221
NFES 1353
6. Actual Release Date/Time
7. Manifest? Yes No Number

8. Destination 9. Notified: Agency Region Area

Dispatch

Name:

Date:
10. Unit Leader Responsible for Collecting Performance Rating

11.
You and your resources have been released subjectUnit/Personnel
to sign off from the following:
Demob. Unit Leader check the appropriate box
Logistics Section

Supply Unit

Communications

Unit Facilities Unit

Ground Support Unit Leader

Planning Section

Documentation Unit

Finance Section

Time Unit

Other

12. Remarks

DEMOBILIZATION
CHECKOUT
1. Incident Name/Number 2. Date/Time 3. Demob. No.

4. Unit/Personnel Released

5. Transportation Type/No.

6. Actual Release Date/Time

7. Manifest? Yes No Number

8. Destination 9. Notified: Agency Region Area

Dispatch

Name:

Date:
10. Unit Leader Responsible for Collecting Performance Rating

11.
Unit/Personnel
ICS 221
NFES 1353
You and your resources have been released subject to sign off from the following:
Demob. Unit Leader check the appropriate box
Logistics Section

Supply Unit

Communications

Unit Facilities Unit

Ground Support Unit Leader

Planning Section

Documentation Unit

Finance Section

Time Unit

Other

12. Remarks

13. Prepared by (include Date and Time)

NFES 1353 ICS 221

 Instructions for completing the Demobilization Checkout (ICS form 221)
Instructions for completing the Demobilization Checkout (ICS form 221)

Prior to actual Demob Planning Section (Demob Unit) should check with the Command Staff (Liaison Officer) to determine any
agency specific needs related to demob and release. If any, add to line Number 11.

Item No. Item Title Instructions

1. Incident Name/No. Enter Name and/or Number of Incident.

2. Date & Time Enter Date and Time prepared.

3. Demob. No. Enter Agency Request Number, Order Number, or Agency Demob Number if
applicable.

4. Unit/Personnel Released Enter appropriate vehicle or Strike Team/Task Force ID Number(s) and Leader’s name
or individual overhead or staff personnel being released.

5. Transportation Enter Method and vehicle ID number for transportation back to home unit. Enter N/A
if own transportation is provided. Additional specific details should be included in
Remarks, block # 12.

6. Actual Release Date/Time To be completed at conclusion of Demob at time of actual release from incident.
Would normally be last item of form to be completed.

7. Manifest Mark appropriate box. If yes, enter manifest number. Some agencies require a
manifest for air travel.

8. Destination Enter the location to which Unit or personnel have been released. i.e. Area,
Region, Home Base, Airport, Mobilization Center, etc.

9. Area/Agency/ Identify the Area, Agency, or Region notified and enter date and time of notification.
Region Notified

10. Unit Leader Responsible for Self-explanatory. Not all agencies require these ratings.
Collecting Performance Ratings

11. Resource Supervision Demob Unit Leader will identify with a check in the box to the left of those units
requiring check-out. Identified Unit Leaders are to initial to the right to indicate
release.

Blank boxes are provided for any additional check, (unit requirements as needed), i.e.
Safety Officer, Agency Rep., etc.

12. Remarks Any additional information pertaining to demob or release.

13. Prepared by Enter the name of the person who prepared this Demobilization Checkout, including
the Date and Time.

ICS 221 NFES

1353
 INSTRUCTIONS: The immediate supervisor will prepare this form for a subordinate
person. Rating will be reviewed with the individual who will sign and date the form.
INDIVIDUAL PERFORMANCE RATING The completed rating will be given to the Planning Section Chief before the rater
leaves the incident

1. NAME 2. INCIDENT NAME AND NUMBER START DATE OF INCIDENT

3. HOME UNIT ADDRESS 4. INCIDENT AGENCY AND ADDRESS

6. TRAINEE POSITION 7. INCIDENT COMPLEXITY

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5. POSITION HELD ON INCIDENT 8. DATE OF ASSIGNMENT
OvEs D NO 01 011 0111 FROM: TO:

PERFORMANCE LEVEL

9. List the main duties from the Position Checklist, on which the c
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position will be rated.
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Enter X under the appropriate column indicating the individuals level i ..5 <I)
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of performance for each duty listed. g :2
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EXPLAIN IN REMARKS

10. REMARKS

11. THIS RATING HAS BEEN DISCUSSED WITH ME (Signature of individual being rated.) 12. DATE

13. RATED BY (Signature) 14. HOME UNIT 15. POSITION HELD ON THIS INCIDENT 16. DATE

-u.s , GPO: 1991-594-696 40141 NFES 2074 1CS FORM 226 (6/89)