Form 1 Rev.

4/7/2007
Department of Health
Center for Health Development – Region 1
HEALTH EMERGENCY MANAGEMENT STAFFF
Brgy. Parian, San Fernando City, La Union
Telefax: (072) 242-7243 / 242-4774 Email: chd1hems@yahoo.com

HEARS FIELD REPORT

(This form must be filled-out & sent to CHD1 HEMS &/or DOH-HEMS, ASAP or w/in 24 hours from start 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: motorcycle
Landslide Cold Spell Infestation Armed Conflict Other, specify_
Lahar Flashflood Terrorism
Date of Event: Time of Event: Exact Location: Calimugtong, Galimuyod, Ilocos Sur
22015
12/09/2019 
11:30-12 AM
AM PM (No., Street, Barangay, Municipality/City, Province, Region)
Brief Description (How the event happened):.
The victim was riding a motorcycle, under the influence of alcohol and was about to pick someone around 11 pm when he
lost his control and accidentally bumped into the Welcome Arch of the incident place. He sustained multiple injury that
causes his death.

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

HEALTH IMPACT POPULATION DISPLACEMENT HEALTH FACILITIES / SERVICES
No. of Deaths: 1 Population displaced? Yes No Number Number
No. of Admitted Patients: 0 No. of Displ. Families: Estimated Available Functional
No. of Outpatients: 0 Actual  Public
No. Missing: 0 No. of Disp. Individuals: Actual Hospitals:
Estimated RHUs:
C. Actions Taken
(Include information on number and types of services, human resource and supplies provided in the field)

1. The NDP assigned in the area coordinated with the Municipal Police regarding the motorcycle accident.

2.

3.
D. Assistance Needed
(Include information on number and types of services, human resource 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:
 Form 5 Rev. 4/7/2007
Department of Health
Center for Health Development – Region 1
HEALTH EMERGENCY MANAGEMENT STAFF
Brgy. Parian, San Fernando City, La Union
Telefax: (072) 242-7243 / 242-4774 Email: chd1hems@yahoo.com

LIST OF CASUALTIES
Event Title: ____________________________________________________
(This form is used to report ALL (old and new) cases of deaths, illnesses, injuries and missing individuals related to a particular health
emergency or disaster. When used to supplement Form 4 (Rapid Health Assessment) or Form 5 (Health Situation Update),
corresponding notation that this list is attached must be indicated on the said forms.

A. Deaths (Old and New Cases)

Name Age Sex Address Cause of Death Date Died
Calimugtong, Galimuyod, Ilocos
1. Nathan Gey Demandante 19 M Multiple Injury 12/10/2019
Sur
2.
3.
4.
Etc.

B. Injured / ill – Admitted (Old and New

Cases)
Date Date
Name Age Sex Address Hospital Diagnosis
Admitted Discharged
1.
2.
3.
4.
Etc.
C. Injured / ill – Not Admitted (Old and New Cases)
Name Age Sex Address Diagnosis Date Seen
1.
2.
3.
4.
Etc.

D. Missing (Old and New Cases)

Name Age Sex Address Remarks
1.
2.
3.
4.
Etc.
Prepared and Submitted by:
Date Prepared: Mobile No.:
Signature: Landline:
Printed Name: Fax No.:
Designation/Office: Email: