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It specifies documentation completion for staff/volunteer identification, patient data including medication and vaccination details, and incident or injury reporting. Completed forms are routed to the Documentation Tracking Unit Leader for filing, with guidance that listed forms may be adapted to local requirements.",{"@graph":63,"@context":110},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/annex-12-forms-forms-and-information-sheets-pod-reimbursement-documentation/161445/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/annex-12-forms-forms-and-information-sheets-pod-reimbursement-documentation/161445.png","ImageObject",442,249,{"name":88,"@type":89},"8796093062539","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-09-24","2026-08-30",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"When must additional forms be completed beyond the incident report?","Question",{"text":108,"@type":109},"If an employee or volunteer receives medical treatment from a hospital or physician, additional forms must be completed and forwarded to the Clinic Safety Officer along with the incident report for a workers’ compensation claim.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},161445,1790129819,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":60,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":121,"file_id":122,"file_url":123,"file_type":124,"file_size":125,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":126,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":79},8796093062539,"Annex 12\nForms\n\u000fForms and Information Sheets\nFor reimbursement purposes, accurate record keeping is essential during POD operations.\nDocumentation shall be completed during POD operations to ensure identification of staffing/volunteers, patient information to include medication/vaccination information, and incident/injury.\nCompleted forms shall be given to the Documentation Tracking Unit Leader for filing.  Example copies of suggested forms are listed below.  These forms are provided; however, they may be modified or replaced with local forms.\nRequired Forms\nStaff/Clinic and Volunteer Sign-In Sheet:  12-2 and 12-4\nClinic Staff Emergency Information Form: 12-3\nName, Address, Patient History (NAPH):  12-5 and 12-6\nIncident/Injury report:  12-7 and 12-8\nDEA Form 222\nInventory Sheet for SNS supplies:  12-9\nMedication Instruction Sheet – when applicable\nImmunization/Vaccination Sheet – when applicable, available from SDDOH/CDC\nVaccination Consent Form – when applicable, available from SDDOH/CDC\nOptional Forms\nShift Schedule*\nIncident Briefing, ICS Form 201\nIncident Objectives, ICS Form 202\nOrganization Assignment List, ICS Form 203\nMedical Plan, ICS Form 206\nOrganizational Chart, ICS Form 207\nIncident Status Summary, ICS Form 209\nCheck In List, ICS Form 211\nGeneral Message, ICS Form 213*\nUnit Log, ICS Form 214*\nDemobilization Plan, ICS Form 221\nDemobilization Checkout, ICS Form 221, page 1\nInstructions for Demobilization, ICS Form 221\nResource Order Form, ICS Form 308\nOther forms as identified to help recoup costs or assist with documentation*\nICS forms can be found at: http://training.fema.gov/EMIWeb/IS/ICSResource/ICSResCntr_Forms.htm\nClinic Staff Emergency Information Form\nDate last updated: __________________________\nCompleted By: ____________________________________________________________\nScreener:  __________________________________________\nDispenser:  _________________________________________\nIncident Report\n\u000fIncident Report (continued)\nPlease forward this form to the Clinic Safety Officer as soon as possible following the incident or near miss.\nNote: If an employee or volunteer receives medical treatment from a hospital or physician, additional forms need to be filled out and forwarded to the Clinic Safety Officer along with the incident report so that a workers’ compensation claim can be filed.\n\u000fInventory Sheet\n_____________________________________\nProvisionary CDC Strategic National Stockpile Authority\n(PRINT NAME AND TITLE)\n____________________________________\nAuthorized Receiving Authority\n(PRINT NAME AND TITLE)\nIf control Schedule II Substances are transferred:\n_____________________________________\nAuthorized Receiving DEA Registrant\n(PRINT NAME AND TITLE)\n_____________________________\n(SIGNATURE AND DATE)\n_____________________________\n(SIGNATURE AND DATE)\n_____________________________\n(SIGNATURE AND DATE)\n_____________________________\n(DEA REGISTRATION NO.)","cbCailQBJaockd97","https://ap.wps.com/l/cbCailQBJaockd97","docx",65968,10,"English","# Forms and Information Sheets\n## Required Forms\n## Optional Forms\n## Incident Report\n## Inventory Sheet","[{\"question\":\"When must additional forms be completed beyond the incident report?\",\"answer\":\"If an employee or volunteer receives medical treatment from a hospital or physician, additional forms must be completed and forwarded to the Clinic Safety Officer along with the incident report for a workers’ compensation claim.\"}]","Annex 12 - Forms - Forms and Information Sheets - POD Reimbursement Documentation | DOCX",1788099837]