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ESR Verification Form - Revise-Dina Joy
ESR Verification Form - Revise-Dina Joy
This document is distri/buted only to limited number of DOH, CHD and concerned agency staff for information of events which may have national/
international implications. Please observe responsible information sharing.
Document Type
I. DETECTION
Source of information:
Date detected:
Time detected:
Time of verification:
Date of declaration:
e. Summary of the health event (Describe what happened, common signs and symptoms, diagnosis, and the timeline of events, and distribution of cases and deaths if
multiple locations are affected) [Note: list summary in bullets]
DOH-EB-AEHMD-QMOP-03-Form2 Rev.6
f. Outcome (indicate counts
of case/s)
Source
No.of No.of No.of
(human/ Etiologic
Type of cases/ positive negative
animal/ Type of Specimen agent/pathogen
Examination done samples cases/ cases/
environment isolated/detected
tested samples samples
etc.)
DOH-EB-AEHMD-QMOP-03-Form2 Rev.6
IV. RESPONSE
Status
Specific Actions taken/Planned
Response Office/Agency Date started (pending/ongoing/
activities
done)
1. Case management
2. Laboratory confirmation
3.Field/Epidemiologic
investigation*
4. Program
management/counter
measures
5. Health education and
promotion
6. Response coordination
mechanism
7. Others
..add rows as needed
*Level of ESU who conducted epidemiologic investigation
(select all that applies)
V. REPORT GENERATION
Name (s) of source(s) of information
Who has been informed?
Prepared by: Reviewed/Noted by: Approved by:
Signature Signature Signature
Name Name Name
Designation/Position Designation/Position Designation/Position
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
DISCLAIMER: Information indicated in this report may change upon further validation or investigation made by the epidemiology and surveillance units and other concerned agencies.
DOH-EB-AEHMD-QMOP-03-Form2 Rev.6