SAMPLE

DISASTER RISK REDUCTION AND MANAGEMENT IN HEALTH

HEALTH REPORT FORM 2

Sample Emergency Operations Center Report, as needed

(SD 2 KRA 2.1 Organized Province-Wide/City-Wide DRRM-H System)

RAPID HEALTH ASSESSMENT

(Source: __________ __________)
(This Form shall be filled-out by a DRRM-H Manager/ Focal Person under the Province/City Emergency Operations Center within 24-48 hours after a major
event or disaster and signed by the PHO/CHO and sent ASAP or within 24 -48 hours to DRRM-H Office of the Center for Health Development upon occurrence
of the event )

Event: ______________
Purpose: To determine the magnitude of an emergency and the health needs and capacity of the affected area/s to
cope.
Instructions: This form shall be submitted within 24 hours upon occurrence of major emergency or disaster.
Complete all the necessary fields. Please attach photos if available.

A. EVENT INFORMATION
Type of Hazard
NATURAL BIOLOGICAL TECHNOLOGICAL SOCIETAL
❑Monsoon Rains ❑Lightning ❑ Poisoning ❑Fire ❑Maritime ❑Bombing ❑Ambush Incident
❑ LPA/ALPA ❑Volcanic ❑ Disease Outbreak ❑Chemical Spills Accident ❑Armed ❑Terrorist Activities
❑ Typhoon Eruption ❑Others, specify ❑Toxic Waste ❑Air Accident Conflict ❑Hostage Taking
❑Storm Surge ❑Lahar ______________ ❑Nuclear ❑ Land ❑ War ❑Coup d’état
❑Flooding ❑Tsunami ❑Damaged Transportation ❑Mass ❑Repatriation
❑Landslide Accident Gathering
Incident Infrastructure ❑Civil Unrest
❑Earthquake ❑Trash slide
❑Others, specify ❑Explosion (Unintentional) ❑Specify______________
______________ ❑Others, specify_______________
Date of Occurrence (dd/mm/yy) Time of Occurrence ❑AM ❑PM
Place of Occurrence Barangay/Landmark Municipality/City Province: Region:
:

Brief Description

B. LIFELINES IN THE AFFECTED AREAS

Lifelines Status Remarks
Communication Landline ❑ Available ❑ Not available
Services
Cellphone ❑ Available ❑ Not available
Internet ❑ Available ❑ Not available
Electricity Services ❑ Available ❑ Not available
❑ Total black out
Water Services ❑ Available ❑ Not available
Main Roads/Bridges ❑ Passable ❑ Not passable
Airports and Seaports ❑ Functional ❑ Not Functional
Source:
 SAMPLE

DISASTER RISK REDUCTION AND MANAGEMENT IN HEALTH

HEALTH REPORT FORM 2

C. IMPACT OF THE EVENT IN THE COMMUNITY

Please attach updated List of Casualties in the prescribed format. (Add more rows if necessary)
Province City/ Number Affected Evacuation Center Casualties
Municipality
Famili Individuals No. of No. of No. of No. of No. of No. of
es EC Familie Individua Deaths Injured victims in
s ls the
hospital

Total:

D. IMPACT OF THE EVENT ON HEALTH FACILITIES

(Add more rows if necessary)
Province City/Municipal No. of No. of No. of Remarks
ity Existing Damaged functional
Facilities facilities facilities
DOH _______ DOH ________ DOH ________
LGU ________ LGU ________ LGU ________
Private_______ Private ________ Private ________
Others: _______ Others: ________ Others: ________

E. HEALTH PERSONNEL
(Add more rows if necessary)
Percent of personnel reporting for Command system in place?
Province | City/ Municipality | Hospital
work
❑ less than 50 percent ❑ Yes ❑ No
❑ more than 50 percent

F. LOGISTICS
Essential Drugs and Medicines
Office
Status For how many days will it last?

CHD ❑ Adequate ❑ Inadequate

LGU ❑ Adequate ❑ Inadequate

Hospitals ❑ Adequate ❑ Inadequate

G. Actions Taken
1.

2.

3.
 SAMPLE

DISASTER RISK REDUCTION AND MANAGEMENT IN HEALTH

HEALTH REPORT FORM 2

H. Recommendations
1.
2.
3.

Prepared and Submitted by:

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