Republic of the Philippines

Department of Health

HEALTH EMERGENCY MANAGEMENT STAFF

Ground Floor, Bldg. 12, San Lazaro Compound

Rizal Avenue, Sta. Cruz, Manila

Telefax: (63-2)711-1001/ 740-5030/ 743-0568 Tel: (63-2)711-1002/ 743-0538

Trunk line Nos. 743-8301 loc 2200 to 2207

Email: ;

RAPID HEALTH ASSESSMENT

Event Title: ______

(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS within 24 hours upon occurrence of a major health emergency or disaster, except for mass casualty incidents and outbreaks, for which Form 3-B and Form 3-C shall be used respectively.)

A. Event Information
Type of Event: / GEOLOGIC
qVolcanic Eruption
qEarthquake
qTsunami
qLandslide
qLahar / WEATHER
qTyphoon
qStorm Surge
qDrought
qCold Spell
qFlashflood / BIOLOGIC
qRed Tide
qFish Kills
qLocust
qInfestation / MAN-MADE
qFire
qExplosion
qArmed Conflict
qTerrorism / qPoisoning, specify ______
qMass Action, specify______
qAccident, specify ______
qOther, specify______
Date of
Occurrence: / Time of qAM
Occurrence: qPM / Exact Location:
Region: Province: Municipality/City:
B. Magnitude of Event
Province / Municipality/ City / Number Affected / Evacuation Centers
Families / Individuals / No. of EC / No. of Families in EC / No. of Indiv. in EC
C. Health Consequences
Province / Municipality/ City / Total No. of Deaths / Total no. of ill / injured
(excluding those who have died) / Total No. of Missing
Admitted / Admitted then Discharged / Not Admitted
Attachments to this Report: qForm 5 (List of Casualties) qOthers (Specify):______
D. Health Facilities in the Affected Areas
DOH Hospital/s: / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
LGU Hospital/s: / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
Pvt. Hospital/s: / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
RHU/Health Ctr: / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
BHS: / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
Other: ______/ qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
E. Lifelines in the Affected Areas
Communication / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
Electric Power / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
Water Supply / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
Roads/Bridges / qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
Transportation
Other: ______/ qFully Functional qPartly Functional qTotally Non-Functional / Remarks:
F. Health Services in the Affected Areas
1.  Immunization / qAdequate qInadequate / Remarks:
2.  Nutrition / qAdequate qInadequate / Remarks:
3.  Consultation / qAdequate qInadequate / Remarks:
4.  Health Education / qAdequate qInadequate / Remarks:
5.  WASH / qAdequate qInadequate / Remarks:
6.  MHPSS / qAdequate qInadequate / Remarks:
G. Public Health Concerns (If applicable)
ENVIRONMENTAL SANITATION
Areas of Concern / Status (Indicate exact location of problem, if any) / Actions Taken
1. Water Supply
2. Latrines
3. Garbage Disposal
4. Drainage
5. Vermin Control
H. Status of Essential Drugs and Supplies in the Affected Areas
No. of Cases / No. of Days / Remarks
Stock Level Good For:
I. Actions Taken
1.
2.
3.
4.
J. Problems Encountered
1.
2.
3.
4.
K. Recommendations
1.
2.
3.
4.
5.

Prepared and Submitted by:

Date Prepared: / Mobile No.:
Signature: / Landline:
Printed Name: / Fax No.:
Designation/Office: / Email: