Form 4-A (p.1/3) Rev.

4/7/2007
Republic of the Philippines
Department of Health
Provincial DOH Office-North Leyte
HEALTH EMERGENCY MANAGEMENT

HEALTH SITUATION UPDATE No. __

Event Title: ________________________________________________________________________________
Data as of: ___________________________________________________________
(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS twice a week for the first two weeks after the occurrence of a
major health emergency or disaster and every week thereafter, until the response activities are terminated or the case is considered closed.
Exceptions to the use of this form include mass casualty incidents and outbreaks, for which Form 4-B and Form 4-C shall be used instead.)

A. Event Information
Any additional information about the event (not previously reported):

B. Magnitude of Disaster (If applicable)

No. of Families No. of Persons
Province Municipality/ City Barangay Population
Affected Affected

C. Lifelines (If applicable)

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 Fully Functional Partly Functional Totally Non-Functional Remarks:
D. Health Consequences (Report cumulative number of casualties from the time the event occurred until the date of this
report)
Total no. of ill / injured (excluding those who have died)
Total Brought to Total
Brought to
Province Municipality/ City No. of hospital – Brought to No. of
Treated on hospital –
Admitted hospital -
Deaths Site Managed Missing
then Still admitted
OPD
discharged

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

 Form 4-A (p.2/3) Rev. 4/7/2007
E. Temporary Shelters (If applicable)
Inside Evacuation Center Outside Evacuation Center
Site of Evacuation
Province Municipality/ City No. of No. of No. of No.of
Center Families Persons Families Persons

F. Morbidity Cases (Report only the NEW cases from the date of last report)
TOP FIVE LEADING CAUSES OF CONSULTATION IN EVACUATION CENTERS (If Applicable)
No. of Cases
Causes
0-15 yrs >15 yrs Total
1.
2.
3.
4.
5.
TOP FIVE LEADING CAUSES OF CONSULTATION OUTSIDE EVACUATION CENTERS
No. of Cases
Causes
0-15 yrs >15 yrs Total
1.
2.
3.
4.
5.
G. Health Facilities (If applicable)
No. Fully No. Partially
No. Existing Remarks
Functional After Functional After the
Before the Event (Names of facilities damaged, Type of damage, etc.)
the Event Event
Govt. Hospital/s: 2
Pvt. Hospital/s:
RHU/s:
Other: ________
H. 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
HEALTH SERVICES
1. Immunization Adequate Inadequate Remarks:
2. Nutrition Adequate Inadequate Remarks:
3. Consultation Adequate Inadequate Remarks:
4. Health Education Adequate Inadequate Remarks:
 Form 4-A (p.3/3) Rev. 4/7/2007
I. Rehabilitation

J. Actions Taken (Report only the NEW actions taken from the date of the last report)
Agency/Office Actions Taken Cost of Assistance
1. DOH-Central Office Actual
Estimate

2. CHD No. ______ Actual

Estimate

3. LGU Actual
Estimate

4. PHO Actual
Estimate

5. CHO/MHO Actual
Estimate

Actual
Estimate

Actual
Estimate

K. Problems Encountered
1.

2.

3.

4.

5.

L. Recommendations
1.

2.

3.

4.

5.

Prepared and Submitted by:

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