• Hospital Diversion Status Form

    Use this form to report, update, and track hospital diversion status, the reason for diversion, affected services, current capacity concerns, and operational follow-up information.

  • Diversion Status Details

  • Current Diversion Status*
  • Status Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Status Effective Time*
  • Reported / Updated At
     - -
    2 digit month, 2 digit day, 4 digit year

  • Operational Impact

  • Reason(s) for Diversion*
  • Affected Areas / Services*
  • Expected End Time
     - -
    2 digit month, 2 digit day, 4 digit year

  • Capacity and Escalation Information

  • Capacity Constraints*
  • Escalation Protocol Activated?*
  • Should be Empty:
Select theme: