Republic of the Philippines

Department of Health
Eastern Visayas
Center for Health Development

Self-Assessment Tool for Temporary Treatment & Monitoring Facilities

for COVID-19

Municipality:___________________ Province:____________________

Facility Name:_______________________________________________________________
Facility Type:
___Auditorium ___ Gymnasium ___School ___Hotel ___Court ___Tent
___Others specify:____________________________
Location/Address: ____________________________________ Facility Contact No.:________________

Facility Manager:
Name: __________________________ Designation: _________________ Contact No.:_______________

Location and Infrastructure

Item YES NO Remarks
1. Located within 2hrs distance from a Level 2 or
3 COVID-19 referral hospital
2. Uninterrupted access to:
Electricity -
Potable water source -
Sewer line -

3. Provision of at least fan ventilation

4. Delineated clearly the following zones:
Contaminated Zone -
Buffer Zone -
Sterile Zone -

5. Separate entrance and exit for patients and staff

6. Unidirectional flow of foot traffic for staff

7. Adequate Toilet and Bath

Water Closet: 1 per 25 M / 1 per 20 F -
Urinal: 1 per 10-50 males, additional -
Showers: 1 per 8 persons -
Lavatory: 1 per 10 males; 1 per 10 females -

8. Facility Divided into three (3) zones:

Contaminated zone (area where patients are
admitted or confined) -
Buffer Zone (area for doffing of PPEs,
decontamination or disinfection & hand hygiene)
-
Sterile Zone (for health staff: holding area,
entrance, area for donning of PPEs, office area) -
9. Donning area is located before entering the

Government Center, Candahug Palo, Leyte ● Tel. /Fax Nos. (053) 323-5027 / (053) 323-5025
doh.region08@gmail.com ● www.ro8.doh.gov.ph
 Republic of the Philippines
Department of Health
Eastern Visayas
Center for Health Development

contaminated zone (Buffer zone)

10. Doffing area is located before entering the

sterile zone (Buffer zone)

Patient Placement
Item YES NO Remarks
11. Individual enclosed rooms

12. Room partitions

13. at least 3 feet apart distances between patient

beds
14. Suspect, probable, and confirmed cases
are placed in a separate area and adheres to
the recommended patient placement
15. Separate Toilet and Bathroom for each patient

For shared Toilet and Bathroom:

Proper hand hygiene after using -
Toilets flushed with lid down -
Frequently touched surfaces are disinfected -
(doorknobs, faucet etc.)
Operations

Item YES NO Remarks

16. Health Human Resource
Pre Deployment Orientation –
Risk Assessment (DC 2020-0106) –
Availability of HR to ensure 24/7 operations –
Provision for Accommodation and transport
(as needed) –

17. Health Care Waste Management

18. Disinfection of Non-Critical Items, and

Environment (Including linen)

19. Provision  of Food Services

20. Health Records

Item YES NO Remarks

21. Reporting to RESU
(Shall report using the COVID-19 Information
Government Center, Candahug Palo, Leyte ● Tel. /Fax Nos. (053) 323-5027 / (053) 323-5025
doh.region08@gmail.com ● www.ro8.doh.gov.ph
 Republic of the Philippines
Department of Health
Eastern Visayas
Center for Health Development

SystemCOVID-19 Information System every

5PM)
Medical Status -
Laboratory Status -
Disposition -
Other remarks -
22. Supply Management

23. Referral Protocols in Place

Transfer -
Diagnostics (as needed) -
Coordination
Item YES NO Remarks
24. Coordination with a COVID-19 Referral
Hospital

25. Availability/ Access to at least Level 1 (BLS)

Ambulance

Contingency Provisions
Item YES NO Remarks
26. Standby Generator in cases of power
interruption. 

Accomplished by:

Name Designation Signature Date

Government Center, Candahug Palo, Leyte ● Tel. /Fax Nos. (053) 323-5027 / (053) 323-5025
doh.region08@gmail.com ● www.ro8.doh.gov.ph