Verification

Regional Epidemiology Surveillance Unit

Event-based Surveillance and Response (ESR) Report
Tel: (064) 421-2196, 421-9586 June 6, 2020
Fax: (064) 421-2196, 421-9586
E-mail: chd12resu@yahoo.com

Classified Document:
Code:
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Document Status INTERNAL

1 Report date and time June 6, 2020 at 10:00Am
2 Verification date and time
3 Health event SUSPECT COVID-19 CASE
4 Location Glan Medicare Community Hospital, Poblacion, Glan, Sarangani Province
5 Start date
6 Number of cases
7 Description of cases NAME:
ADDRESS:
AGE: SEX: C/S: CONTACT NUMBER:
DATE OF BIRTH:
OCCUPATION:
TRAVEL HISTORY:
HISTORY OF EXPOSURE TO SUSPECT/PROBABLE/CONFIRMED COVID-19 CASES:
ADMITTING DX:
CHIEF COMPLAINT/S:
HEALTH HISTORY:
P.E.: BP: mmHg; T=˚C; RR=cpm; HR=cpm; WT:
COVID-19 CATEGORICAL QUALIFIER:
STATUS:

8 Number of deaths 0
9 Description of deaths
10 Status of health event
11 Actions taken  CASE MANAGEMENT
 REPORTED TO MESU, PESU, PHO
12 Assessment
13 Assistance needed
14 Remarks
15 Laboratory results
16 ESRU Action
17 Who has been informed? MESU, PESU, PHO
18 Source(s) of information MEDICAL RECORDS, RESPI UNIT STAFF, GMCH;
19 Prepared by: LELAND C. DAGOY, RN, MAN NURSE II/GMCH HESU 09177219051
20 Noted by: RICHEL T. DEYAYA, RN, MAN CHIEF, NURSING SERVICE GMCH

*Public Health Event of Local (L), Regional (R), National (N) Concern
** Public Health Emergency of International Concern (PHEIC); according to WHO-International Health Regulation Definition
***Captured by National ESR Staff

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contained in this list, the reader assumes all risks in connection with such use. The NEC shall not be held responsible for errors, omissions nor liable for any special,
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DOH-NEC-APHD-QMOP-03-Form2 Rev.4