Republic of the Philippines

Department of Health
REGIONAL OFFICE IV-A
HEALTH EMERGENCY MANAGEMENT STAFF
CaLaBaRZon
QMMC Compound, Project 4, Quezon City
Trunkline No.: 990.4067 to 74 local 119, 120, 122/ Direct line: 440.3551/ 440.3372
Telefax: 913.3616
E-Mail Add.: chd4a_doh_calabarzon@yahoo.com
hemsopcen.calabarzon@gmail.com

RAPID HEALTH ASSESSMENT (OUTBREAK)

FOR : JANETTE L. GARIN, MD, MBA – H
Secretary of Health

FROM : RIO L. MAGPANTAY, MD, PHSAE, CESO III

Director IV

SUBJECT : _____________________________________

ACTION DESIRED : FOR YOUR INFORMATION AND PERUSAL

Event Title: __________________________________________________________________

(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS within 24 hours upon occurrence of the outbreak.)

A. Event Information
Type of Event: Epidemic, specify:
Date of Time of AM Exact Location:
Occurrence: Occurrence: PM Region: Province: Municipality/City:
B. Health Consequences
Total No. of Total No. of Total No. of Cases (Excluding those who have died)
Treated on Brought to hospital – Brought to hospital – Brought to hospital -
Persons Exposed Deaths Site Managed OPD Admitted then discharged Still admitted

Attachments to this Report: Form 5 (List of Casualties) Others (Specify):__________________________________________

C. Actions Taken
1.

2.

3.

4.

5.

D. Problems Encountered
1.

2.

3.

4.

5.

E. Recommendations
1.
2.

3.

4.

5.

Prepared and Submitted by:

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