Form 1 Rev.

4/7/2007
Republic of the Philippines
Department of Health
Center for Health Development in Eastern Visayas
HEALTH EMERGENCY MANAGEMENT STAFF
Government Center, Candahug, Palo, Leyte
Telefax: (053)-323-5069 / 323-6517 Tel: (053)- 323-6117/ 323-5027/323-5028
Email: chd8_hems@yahoo.com

HEARS FIELD REPORT

(Upon learning about the occurrence of an event, the HEMS Coordinator shall immediately inform the DOH-HEMS Operation Center through the
fastest communication means available. Then this Form 1 shall be filled-out and sent ASAP or within 24 hours upon occurrence of the event.)

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

B. Consequences (Supply as much data as possible within 24 hours)

HEALTH IMPACT POPULATION DISPLACEMENT HEALTH FACILITIES / SERVICES
No. of Deaths: Population displaced? Yes No Number Number
No. of Admitted Patients: No. of Displ. Families: Estimated Available Functional
No. of Outpatients: Actual Public
No. Missing: No. of Disp. Individuals: Actual Hospitals:
Estimated RHUs:
C. Actions Taken (Include information on number and types of services, manpower and supplies provided in the field)
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2.
3.
4.
5.

D. Assistance Needed (Include information on number and types of services, manpower and supplies needed in the field)
1.
2.
3.
4.
5.
Prepared and Submitted by:
Date Prepared: Mobile No.:
Signature: Landline:
Printed Name: Fax No.:
Designation/Office: Email: