Form 1 Rev.

4/7/2007
Republic of the Philippines
Department of Health
HEALTH EMERGENCY MANAGEMENT STAFF
Ground Floor, Bldg. 12, San Lazaro Compound
Rizal Avenue, Sta. Cruz, Manila
Telefax: (63-2)711-1001/ 740-5030/ 743-0568 Tel: (63-2)711-1002/ 743-0538
Trunk line Nos. 743-8301 loc 2200 to 2207
Email: doh_hems@yahoo.com; doh_hemsopcen@yahoo.com

RAPID HEALTH ASSESSMENT (MCI)

Event Title: _____________________________________________________
(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS within 24 hours upon occurrence of the health emergency
or disaster resulting to a mass casualty incident.

A. Event Information
Type of Event: GEOLOGIC WEATHER BIOLOGIC MAN-MADE
Volcanic Eruption Typhoon Red Tide Fire Poisoning, specify ______________
Earthquake Storm Surge Fish Kills Explosion Mass Action, specify____________
Tsunami Drought Locust Armed Conflict Accident, specify ______________
Landslide Cold Spell Infestation Terrorism Other, specify_________________
Lahar Flashflood
Date of Time of AM Exact Location:
Occurrence: Occurrence: PM Region: Province: Municipality/City:
B. Health Consequences
Total No. of Total no. of ill / injured (Excluding those who have died) Total No. of
Treated on Brought to hospital – Brought to hospital – Brought to hospital -
Deaths Site Managed OPD Admitted then discharged Still admitted
Missing

Attachments to this Report: Form 5 (List of Casualties) Others (Specify):__________________________________________

C. Actions Taken
1.

2.

3.

D. Problems Encountered
1.

2.

3.

E. Recommendations
1.

2.

3.

Prepared and Submitted by:

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