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

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 Flashflood 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)
1.
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: