LINE 1 -- DATE AND TIME______________________________(DTG)
LINE 2 -- UNIT________________________________________(Unit Making Report)
LINE 3 -- ELEMENT____________________________________(Name or Designator of the Reporting Element)
LINE 4 -- TOTAL OPERATIONAL ________________________(Total Number of Beds That Are Operational)
LINE 5 -- MEDICAL OPERATIONAL______________________(Number of Medical (MM) Beds Operational)
LINE 6 -- PSYCHIATRIC OPERATIONAL__________________(Number of Psychiatric (MP) Beds Operational)
LINE 7 -- GENERAL OPERATIONAL______________________(Number of General Surgeries (SS) Beds Operational)
LINE 8 -- ORTHOPEDIC OPERATIONAL___________________(Number of Orthopedic (SO) Beds Operational)
LINE 9 -- BURN OPERATIONAL _________________________(Number of Burn (SB) Beds Operational)
LINE 10 -- SPINAL CORD OPERATIONAL_________________(Number of Spinal Cord (SC) Injury Beds Operational)
LINE 11 -- OB/GYN OPERATIONAL______________________(Number of OB/GYN (SG) Beds Operational)
LINE 12 -- PEDIATRIC OPERATIONAL____________________(Number of Pediatric (MC) Beds Operational)
LINE 13 -- NEURO OPERATIONAL_______________________(Number of Neurosurgery (SSN) Beds Operational)
LINE 14 -- ORAL OPERATIONAL_________________________(Number of Oral/Maxillofacial (SSM) Operational)
LINE 15 -- OPHTHALMOLOGY OPERATIONAL____________(Number of Ophthalmology (SSO) Beds Operational)
LINE 16 -- THORACIC OPERATIONAL____________________(Number of Thoracic Surgery (SSC) Beds Operational)
**Use lines 13 through 16 to report the number of operational beds in selected surgical sub-specialties. Include these numbers in line 6.
LINE 17 -- AVAILABLE TOTAL__________________________(Total Number of Available Beds)
LINE 18 -- AVAILABLE MEDICAL________________________(Number of Medical (MM) Beds Available)
LINE 19 -- AVAILABLE PSYCHIATRIC____________________(Number of Psychiatric (MP) Beds Available)
LINE 20 -- AVAILABLE GENERAL________________________(Number of General Surgery (SS) Beds Available)
LINE 21 -- AVAILABLE ORTHOPEDIC ____________________(Number of Orthopedic (SO) Beds Available)
LINE 22 -- AVAILABLE BURN___________________________(Number of Burn (SB) Beds Available)
LINE 23 -- AVAILABLE SPINAL CORD____________________(Number of Spinal Cord (SC) Injury Beds Available)
LINE 24 -- AVAILABLE OB/GYN_________________________(Number of OB/GYN (SG) Beds Available)
LINE 25 -- AVAILABLE PEDIATRIC ______________________(Number of Pediatric (MC) Beds Available)
**Use lines 17 through 25 to report the number of available beds for patients at the reporting medical element.
LINE 26 -- AVAILABLE NEURO__________________________(Number of Neurosurgery (SSN) Available)
LINE 27 -- AVAILABLE ORAL___________________________(Number of Oral/Maxillofacial (SSM) Beds Available)
LINE 28 -- AVAILABLE OPHTHALMOLOGY_______________(Number of Ophthalmology (SSO) Beds Available)
LINE 29 -- AVAILABLE THORACIC_______________________(Number of Thoracic Surgery (SSC) Beds Available)
**Use lines 26 through 29 to report the number of available beds in selected surgical sub-specialties. Include these numbers in line 19.
LINE 30 -- SUITES_____________________________________(Number of Operating Suites That Are Operational)
LINE 31 -- BACKLOG__________________________________(Number of Hours Surgical Backlog)
LINE 32 -- OVERFLOW_________________________________(Number of Overflow/ Holding Beds Available)
LINE 33 -- NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report
**Use lines 30 through 33 to provide additional information concerning medical element status, workload, and other amplifying data.
**Repeat lines 3 through 33 for multiple missions or sets of mission data. Assign sequential line numbers to succeeding iterations; for example, first iteration 11 through 15; second iteration 11a through 15a; third iteration 11b through 15b; and so on.
LINE 34 -- AUTHENTICATION___________________________(Report Authentication)