Incident Date:	Start Time:	Finish Time:

Facility:	Location:

Activation Date:	Time:	Deployment ready at:

Activated by:	Incident Commander:

CERT Commander:

Team Members

Summary of the Incident

Description of the Planned Action

Injuries

Property Damage

Munitions Spent

What Worked and/or Problems Encountered

Action Plan:

Reviewed By:

Incident Commander:	Date:

Facility Head:	Date:

Emergency Coordinator:	Date:

Deputy Chief:	Date:

Chief:	Date: