Line 1: Location of the pick-up site: _______________________________________
Line 2: Radio frequency, call sign and suffix: _______________________________________
Line 3: Number of patients of precedence: _______________________________________
A – Urgent;
B – Urgent surgical;
C – Priority;
D – Routine;
E – Convenience.
Line 4: Special equipment required: _______________________________________
A – None;
B – Hoist;
C – Extraction equipment;
D – Ventilator.
Line 5: Number of patients: _______________________________________
A – Litter;
B – Ambulatory.
Line 6: Security at pick-up site: _______________________________________
(in peacetime – number of wounds, injuries, and illnesses)
A – No enemy troops in area;
B – Possible enemy troops in area (approach with caution);
C – enemy troops in area (approach with caution);
D – enemy troops in area (armed escort required).
Line 7: Method of pick-up site marking: _______________________________________
A – Panel;
B – Pyrotechnic signal;
C – Smoke signal;
D – None; E – Other
Line 8: Patient nationality and status: _______________________________________
A – US military;
B – US civilian;
C – Non-US military;
D – Non-US civilian;
E – EPW
Line 9: NBC contamination: _______________________________________
(in peacetime – terrain description of pick-up site)
N – Nuclear;
B – Biological
C – Chemical
MEDEVAC request – example
And here is an example of a MEDEVAC request:
Line 1: 42W XC 34590 43291
Line 2: 151.57250 FM, COYOTE 01
Line 3: A – 1; D – 2
Line 4: Alpha
Line 5: A – 1; B – 2.
Line 6: Bravo
Line 7: Charlie, green
Line 8: Charlie – 2; Echo – 1.
Line 9: None