RO HEMS FORM 2 –EVENT NAME- REF#

Republic of the Philippines

Department of Health
Regional Office 02
HEALTH EMERGENCY MANAGEMENT STAFF
REPORTING UNIT: _______________

RAPID HEALTH ASSESSMENT

As of (mm/dd/yyyy): ____________________

Event: ______________
Purpose: To determine the magnitude of an emergency and the health needs and capacity of the affected area/s to
cope.
Instructions: This form shall be submitted within 24 hours upon occurrence of major emergency or disaster.
Complete all the necessary fields. Please attach photos if available.

A. EVENT INFORMATION
Type of Hazard
NATURAL BIOLOGICAL TECHNOLOGICAL SOCIETAL
Monsoon Rains Lightning  Poisoning Fire Maritime Bombing Ambush Incident
 LPA/ALPA Volcanic  Disease Outbreak, Chemical Spills Accident Armed Terrorist Activities
Tropical Eruption specify disease: Toxic Waste Air Accident Conflict Hostage Taking
Depression Lahar ________________ Nuclear  Land War Coup d’état
Typhoon Tsunami  Damaged Transportation Mass Repatriation
Storm Surge Landslide Others, specify Infrastructure Accident Gathering Civil Unrest
Flooding ______________ Trash slide
Earthquake
Others, specify Explosion (Unintentional) Specify______________
______________ Others, specify_______________

Date of Occurrence (dd/mm/yy) Time of Occurrence AM PM

Place of Occurrence Barangay/Landmark Municipality/City Province: Region:
:

Brief Description

B. LIFELINES IN THE AFFECTED AREAS

Lifelines Status Remarks
Communication Landline  Available  Not available
Services
Cellphone  Available  Not available
Internet  Available  Not available
Electricity Services  Available  Partially available 
 Total black out 
Water Services  Available  Not available
Main Roads/Bridges Passable  Not passable
Airports  Functional  Not Functional
Seaports  Functional  Not Functional 
Source:

C. IMPACT OF THE EVENT IN THE COMMUNITY

Please attach updated List of Casualties in the prescribed format. (Add more rows if necessary)
Province City/ Number of Affected No. of Casualties Evacuation Center
Municipality Population
Families Individuals Deaths Injured/ ILL Total Total No. Total No. of
No. of of Individuals
Pre- Hospital EC Families inside EC
Hos OPD Admitted inside EC
pital

Total:
RO HEMS FORM 2 RAPID HEALTH ASSESMENT 2014

Building 12, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Trunk Line 651-7800 Direct Line: 711-1001
Fax: 711-1002 ● URL: http://www.doh.gov.ph; e-mail: [email protected]
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 RO HEMS FORM 2 –EVENT NAME- REF#

Republic of the Philippines

Department of Health
Regional Office 02
HEALTH EMERGENCY MANAGEMENT STAFF
REPORTING UNIT: _______________
Source:

D. IMPACT OF THE EVENT ON HEALTH FACILITIES

(Add more rows if necessary)
No. of Health Facilities
Province City/ Existing Damaged Functional Non- Remarks
Municipality (Baseline) Functional
DOH ____ DOH ____ DOH ____ DOH ____
LGU ____ LGU ____ LGU ____ LGU ____
Military ____ Military ____ Military ____ Military ____
Private ____ Private ____ Private ____ Private ____
Others: ____ Others: ____ Others: ____ Others: ____

E. HEALTH PERSONNEL
(Add more rows if necessary)
Command system in
City/ Percent of personnel reporting to
Province Health Facility place?
Municipality work
CHD  less than 50 percent  Yes  No
 more than 50 percent
PHO  less than 50 percent  Yes  No
 more than 50 percent
MHO  less than 50 percent  Yes  No
 more than 50 percent
RHU  less than 50 percent  Yes  No
 more than 50 percent
DOH Hospitals  less than 50 percent  Yes  No
 more than 50 percent

F. LOGISTICS
Essential Drugs and Medicines
Office
Status For how many days will it last?

CHD Adequate Inadequate

LGU Adequate Inadequate

Hospitals Adequate Inadequate

G. Actions Taken
LGU DOH REGIONAL OFFICE DOH CENTRAL OFFICE
□ Established Command Center □ Established □ Established Command / Operation
□ Transport to Hospitals Command/Operation Center Center in the affected areas
□ Admission to Hospitals □ Transport to Hospitals □ Deployed Response Teams
□ Outpatient Care □ Admission to Hospitals □ Rapid Health Assessment
□ Provided Drinking water □ Outpatient Care □ Mobilized Logistics
□ Evacuated Affected Population □ Mobilized Logistics □ Provided Potable Drinking water
□ Management of the Dead & the □ Deployed Response Teams □ No details on actions taken
Missing □ Provided Drinking water
□ Rapid Health Assessment □ Rapid Health Assessment
□ No details on actions taken □ No details on actions taken

Other Actions Taken

LGU:

DOH REGIONAL OFFICE:

DOH CENTRAL OFFICE:

Prepared and Submitted by:

Date Prepared: Mobile No.:
Printed Name: Landline:
Designation/Office: Fax No.:
RO HEMS FORM 2 RAPID HEALTH ASSESMENT 2014

Building 12, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Trunk Line 651-7800 Direct Line: 711-1001
Fax: 711-1002 ● URL: http://www.doh.gov.ph; e-mail: [email protected]
Page 2 of 3
 RO HEMS FORM 2 –EVENT NAME- REF#

Republic of the Philippines

Department of Health
Regional Office 02
HEALTH EMERGENCY MANAGEMENT STAFF
REPORTING UNIT: _______________
Signature Email:

RO HEMS FORM 2 RAPID HEALTH ASSESMENT 2014

Building 12, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Trunk Line 651-7800 Direct Line: 711-1001
Fax: 711-1002 ● URL: http://www.doh.gov.ph; e-mail: [email protected]
Page 3 of 3