National Epidemiology Center

Event-based Surveillance and Response (ESR)

Tel: (02) 651-7800 loc 2927, 731-3726

Fax: (02) 732-9057

E-mail: Date of this Report

Classified Document:

This document is distributed only to limited number of DOH and selected NGO staff in order to improve common awareness on reports and rumours of events which may have national/ international implications. Please send new or additional information on this or other public health events.

Document Status / DRAFT/INTERNAL/PUBLIC/FYI
1 / Report date and time / Date and time the health event was first reported to the ESR unit.
2 / Verification date and time / Date and time the health event was confirmed/verified by the health staff.
3 / Health event / What happened? (based on initial investigation and/or as described by the reporting health authority)
4 / Location / Brgy., Municipality, City, Province, Region or hospital or company
5 / Start date / Date of onset of 1st case or start of event
6 / Number of cases / How many were affected?
7 / Description ofcases / Who were affected? When? Where? (age, sex, etc...)
8 / Number of deaths / Number of previously reported deaths
9 / Description ofdeaths / Who? When? Where? Why?
10 / Is this an outbreak? / Yes No
If yes, who made the announcement? NEC-DOH RESU-CHD CHO/PHO
Others, specify: ______
Was a report made? Yes No
11 / Actions taken / What was done? By whom? When?
12 / Status of health event / On verification / Ongoing / Controlled / Closed
13 / Assessment / PHELC / PHERC / PHENC / PHEIC
14 / Assistance needed / Specify or put None if not needed
15 / Remarks / Other important information not elsewhere mentioned
16 / Laboratory results / Laboratory findings as to specimens, date collected, result, etc . . .
990 / ESRU Action / To just continue monitoring or will assistance be provided, etc . . .
991 / Who has been informed? / DOH offices, LHO, WHO, other stakeholders
992 / Source(s) of information / Name, Office and contact numbers (landline/cellphone)
993 / Prepared by: / Name of FETP Fellow or ESR Staff on Duty, designation and contact numbers
Noted by: / Name of the supervisor on duty and his/her contact number
Approved by:

*Public Health Event of Local (L), Regional(R), National (N) Concern

** Public Health Emergency of International Concern (PHEIC); according to WHO-International Health Regulation Definition

***Captured by National ESR Staff

DISCLAIMER: Every effort has been made to provide accurate, up-to-date information. However, the knowledge base is dynamic and errors can occur. By using the information contained in this list, the reader assumes all risks in connection with such use. The NEC shall not be held responsible for errors, omissions nor liable for any special, consequential or exemplary damages resulting, in whole or in part, from any reader's use or reliance upon this material.

DOH-NEC-APHD-QMOP-03-Form2 Rev.3