Republic of the Philippines

City Government of Puerto Princesa

CITY HEALTH OFFICE
2/F Old City Hall, Brgy. Sta Monica, Puerto Princesa City
Telephone (048) 433-0042; email: Hemschoppc@gmail.com

LIST OF CASUALTIES (MCI)

Event Title: ________________________________________________________________

A. DEATHS
NAME AGE SEX ADDRESS Cause of Death Date Died

1.

2.

3.

4.

5.

B. INJURED/ILL ADMITTED
Date Date
NAME AGE SEX ADDRESS Hospital Diagnosis
Admitted Discharged
1.

2.

3.

4.

5.

C. INJURED/ILL NOT ADMITTED

Date Date
NAME AGE SEX ADDRESS Hospital Diagnosis
Admitted Discharged
1.

2.

3.

4.

5.

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AJB/2022
 Republic of the Philippines
City Government of Puerto Princesa
CITY HEALTH OFFICE
2/F Old City Hall, Brgy. Sta Monica, Puerto Princesa City
Telephone (048) 433-0042; email: Hemschoppc@gmail.com

D. MISSING
Date Date
NAME AGE SEX ADDRESS Hospital Diagnosis
Admitted Discharged
1.

2.

3.

4.

5.

E. Problems Encountered
1.

2.

3.

4.

5.

Prepared and Submitted by:

Date Prepared: Mobile No.:

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

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AJB/2022