MEDICAL EVACUATION REQUEST [MEDEVAC]
LINE 1 — DATE AND TIME______________________________(DTG)
LINE 2 — UNIT________________________________________(Unit Making Report)
LINE 3 — LOCATION___________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator) of Pickup Site Location; Encrypt if Using Non-Secure Means of Communication)
LINE 4 — RADIO FREQUENCY___________________________(Radio Frequency at Pickup Site; Call Sign, and Suffix)
LINE 5 — NUMBER OF PATIENTS(P)______________________(Number of Patients by Precedence. Report Only Applicable Information and Encrypt the Brevity Codes:
A — URGENT
B — URGENT-SURG
C — PRIORITY
D — ROUTINE
E — CONVENIENCE)
If two or more categories must be reported in the same request, insert the word BREAK between each category.)
LINE 6 — SPECIAL EQUIPMENT__________________________(Encrypt the Applicable Brevity Codes.
A — None
B — Hoist
C — Extraction Equipment)
LINE 7 — NUMBER OF PATIENTS(T)______________________(Total Number of Patients by Type. L + # of PNT — Litter / A + # of PNT — Ambulatory)
LINE 8 — SECURITY OF PICK-UP SITE____________________(N — No Enemy Troops in Area
P — Possibly Enemy Troops in Area (approach with caution)
E — Enemy Troops in Area (approach with caution)
X — Enemy Troops in Area (armed escort required))
LINE 9 — NO. TYPE OF WOUND, INJURY, OR ILLNESS (PEACETIME)
_____________________________________________________(Specific Information Regarding Patient Wounds by Type)
LINE 10 — METHOD OF MARKING AT PZ_________________(Encrypt the Brevity Codes:
A — Panels
B — Pyrotechnic signal
C — Smoke Signal
D — None
E — Other)
LINE 11 — PATIENT NATIONALITY ______________________(Number of Patients in Each
Category Need Not be Transmitted. Encrypt Only the Applicable Brevity Codes:
A — US Military
B — US Civilian
C — Non-US Military
D — Non-US Civilian
E — EPW)
LINE 12 — NBC CONTAMINATION ______________________(NBC Contamination; Use Brevity Codes:
N = Nuclear
B = Biological
C = Chemical
U = Unknown
A = All Clear)
LINE 13 — TERRAIN DESCRIPTION ______________________(Description of Terrain Features at the Proposed Pick-up Site)
LINE 14 — AUTHENTICATION___________________________(Report Authentication)
