Form 1 Rev. 4/7/2007
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: doh_hems@yahoo.com; doh_hemsopcen@yahoo.com
HEALTH SITUATION UPDATE No. __
Event Title: ________________________________________________________________________________
(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS twice a week for the first two weeks after the occurrence
of a major health emergency or disaster and every week thereafter, until the response activities are terminated or the case is considered closed.
Exceptions to the use of this form include mass casualty incidents and outbreaks, for which Form 4-B and Form 4-C shall be used instead.)
A. Event Information
Any additional information about the event (not previously reported):
B. Magnitude of Disaster (If applicable)
Province
Municipality/ City
C. Lifelines (If applicable)
Fully Functional
Communication
Barangay
Population
Partly Functional Totally Non-Functional
Remarks:
Electric Power
Fully Functional Partly Functional Totally Non-Functional
Remarks:
Water Supply
Fully Functional Partly Functional Totally Non-Functional
Remarks:
Roads/Bridges
Fully Functional Partly Functional Totally Non-Functional
Remarks:
Transportation
Fully Functional Partly Functional Totally Non-Functional
Remarks:
No. of Families
Affected
No. of Persons
Affected
D. Health Consequences (Report cumulative number of casualties from the time the event occurred until the date of this report)
Total no. of ill / injured (excluding those who have died)
Province
Municipality/ City
Total
No. of
Deaths
Treated on
Site
Brought to
hospital –
Managed
OPD
Brought to
hospital –
Admitted
then
discharged
Brought to
hospital Still admitted
Total
No. of
Missing
Attachments to this Report: Form 5 (List of Casualties) Others (Specify):__________________________________________
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Form 4-A (p.2/3) Rev. 4/7/2007
E. Temporary Shelters (If applicable)
Province
Municipality/ City
Site of Evacuation
Center
Inside Evacuation Center
No. of
No. of
Families
Persons
Outside Evacuation Center
No. of
No.of
Families
Persons
F. Morbidity Cases (Report only the NEW cases from the date of last report)
TOP FIVE LEADING CAUSES OF CONSULTATION IN EVACUATION CENTERS (If Applicable)
Causes
0-15 yrs
No. of Cases
>15 yrs
Total
1.
2.
3.
4.
5.
TOP FIVE LEADING CAUSES OF CONSULTATION OUTSIDE EVACUATION CENTERS
Causes
0-15 yrs
No. of Cases
>15 yrs
Total
1.
2.
3.
4.
5.
G. Health Facilities (If applicable)
No. Existing
Before the Event
No. Fully
Functional After
the Event
No. Partially
Functional After the
Event
Remarks
(Names of facilities damaged, Type of damage, etc.)
Govt. Hospital/s:
Pvt. Hospital/s:
RHU/s:
Other: ________
H. Public Health Concerns (If applicable)
Areas of Concern
1. Water Supply
ENVIRONMENTAL SANITATION
Status (Indicate exact location of problem, if any)
Actions Taken
2. Latrines
3. Garbage Disposal
4. Drainage
5. Vermin Control
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Form 4-A (p.3/3) Rev. 4/7/2007
HEALTH SERVICES
1. Immunization
Adequate Inadequate
Remarks:
2. Nutrition
Adequate Inadequate
Remarks:
3. Consultation
Adequate Inadequate
Remarks:
4. Health Education
Adequate Inadequate
Remarks:
5. Psychosocial
Adequate Inadequate
Remarks:
I. Rehabilitation
J. Actions Taken (Report only the NEW actions taken from the date of the last report)
Agency/Office
Actions Taken
1. DOH-Central Office
Cost of Assistance
Actual
Estimate
2. CHD No. ______
Actual
Estimate
3. LGU
Actual
Estimate
4. PHO
Actual
Estimate
5. CHO/MHO
Actual
Estimate
Actual
Estimate
Actual
Estimate
K. Problems Encountered
1.
2.
3.
4.
5.
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L. Recommendations
1.
2.
3.
4.
5.
Prepared and Submitted by:
Date Prepared:
Signature:
Printed Name:
Designation/Office:
Mobile No.:
Landline:
Fax No.:
Email:
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