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    RHA Blank

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    Jen Signio
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    RHA Blank

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    of 1

    CHD REPORTING FORM 9

    Republic of the Philippines


    Department of Health
    HEALTH EMERGENCY MANAGEMENT STAFF
    Reporting Agency: _____________

    RAPID HEALTH ASSESSMENT


    FOR EVACUATION CENTER/COMMUNITY
    Date Prepared

    Event Name: ______________________________

    A. GENERAL INFORMATION
    Name of Evacuation Center/ Date of Encampment
    Community
    Barangay: Municipality/City: Province: Region
    Address
    Size/Capacity of the evacuation Type of Evacuation Center
    center (estimated lot/floor area, no. of Gym School Church Tent Others
    buildings, no. of rooms) (specify)
    Is there a camp management committee? Name of Camp Manager: Contact #:
    Yes No

    B. Displaced Population Profile as of this date


    Displaced Population Families Individuals
    Inside Evacuation Center
    Outside Evacuation Center
    Age Group No. Vulnerable Groups No.
    Infant (0-11 months) Pregnant Women
    Children 12-59 months old Lactating Women
    5 - 59 years old Persons with Disability
    Senior Citizens
    Total Total:

    D. Public Health Services


    HEALTH Status/Actions Taken Specifics
    Medical Consultations Available Yes No Daily On call Nearby Facility

    Drugs and Medicines Available? Yes No


    Bottled No. ________ Rationed No.
    Water Source? Yes No Hand pump No. ______ Tap/Faucet No. ______

    Portalet number ______ Flush number. _______


    Toilets Yes  No Pit Latrines number. _______
    Others, specify type and number ______

    E. ISSUES AND CONCERNS


    1.
    2.
    3.
    4.
    5.

    Prepared and Submitted by:


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

    Page 1 of 1

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