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
Form 3-A (p.2/2) Rev. 4/7/2007

RAPID HEALTH ASSESSMENT

Event Title: TROPICAL STORM URDUJA
(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS within 24 hours upon occurrence of a major health
emergency or disaster, except for mass casualty incidents and outbreaks, for which Form 3-B and Form 3-C shall be used respectively.)

A. Event Information
Type of Event: GEOLOGIC WEATHER BIOLOGIC MAN-MADE
Volcanic Eruption Typhoon Red Tide Fire Poisoning, specify ______________
Earthquake Storm Surge Fish Kills Explosion Mass Action, specify____________
Tsunami Drought Locust Armed Conflict Accident, specify ______________
Landslide Cold Spell Infestation Terrorism Other, specify_________________
Lahar Flashflood
Date of Time of AM Exact Location:
Occurrence: Occurrence: PM Region: Province: Municipality/City:

B. Magnitude of Event
Municipality/ Number Affected Evacuation Centers
Province
City Families Individuals No. of EC No. of Families in EC No. of Indiv. in EC

C. Health Consequences
Total No. Total no. of ill / injured Total No.
(excluding those who have died)
Province Municipality/ City of of
Admitted then Not
Deaths Admitted
Discharged Admitted Missing

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

D. Health Facilities in the Affected Areas
DOH Hospital/s: Fully Functional Partly Functional Totally Non-Functional Remarks:
LGU Hospital/s: Fully Functional Partly Functional Totally Non-Functional Remarks:
Pvt. Hospital/s: Fully Functional Partly Functional Totally Non-Functional Remarks:
RHU/Health Ctr: Fully Functional Partly Functional Totally Non-Functional Remarks:
BHS: Fully Functional Partly Functional Totally Non-Functional Remarks:
Other: ________ Fully Functional Partly Functional Totally Non-Functional Remarks:
E. Lifelines in the Affected Areas
Communication Fully Functional 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
Other: ________ Fully Functional Partly Functional Totally Non-Functional Remarks:
F. Health Services in the Affected Areas
1. Immunization Adequate Inadequate Remarks:
2. Nutrition Adequate Inadequate Remarks:
3. Consultation Adequate Inadequate Remarks:
4. Health Education Adequate Inadequate Remarks:
5. WASH Adequate Inadequate Remarks:
6. MHPSS Adequate Inadequate Remarks:

G. Public Health Concerns (If applicable)

ENVIRONMENTAL SANITATION
Areas of Concern Status (Indicate exact location of problem, if any) Actions Taken
1. Water Supply
2. Latrines
3. Garbage Disposal
4. Drainage
5. Vermin Control

H. Status of Essential Drugs and Supplies in the Affected Areas

No. of Cases No. of Days Remarks
Stock Level Good For:

I. Actions Taken
1.

2.

3.

4.

J. Problems Encountered
1.

2.

3.

4.
K. Recommendations
1.

2.

3.

4.

5.

Prepared and Submitted by:

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