SAMPLE

DISASTER RISK REDUCTION AND MANAGEMENT IN HEALTH

HEALTH REPORT FORM 1

Sample Emergency Operations Center Report, as needed

(SD 2 KRA 2.1 Organized Province-Wide/City-Wide DRRM-H System)

HEARS FIELD REPORT

(Source: __________ __________)
(Upon learning about the occurrence of an event, the DRRM-H Manager/Focal under the Province/City Emergency Operations Center shall immediately inform the Province/City EOC through the fastest communication means available. Then this Form shall be filled-out by a

DRRM-H Focal Person and signed by the PHO/CHO and sent ASAP or within 24 hours to DRRM-H Office of the Center for Health Development upon occurrence of the event. In the event that there is no major event that occurred in the last 24 hours, kindly notify the Province/City

Emergency Operations Center.

Event Title ______________

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 Exact Location:

Occurrence: Occurrence: Region:

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

❑ ❑
Available Functional
No. of Admitted Patients: No. of Displ. Families: Estimated
❑

No. of Outpatients: Actual Public Hospitals:

❑

No. Missing: No. of Disp. Individuals: Estimated

❑

Actual RHUs:
❑

C. Actions Taken (Include information on number and types of services, human resources for health and supplies provided in the area)

1.

2.

3.

Prepared and Submitted by:

Date Prepared: Mobile No:

Signature: Landline:

Printed Name: Fax No.:

Designation/Office: Email:

Signature: