Form 3-A (p.1/2) Rev.

4/7/2007
Republic of the Philippines
Department of Health
HEALTH EMERGENCY MANAGEMENT STAFF
2nd Flr. ER Trauma Ext. Bldg., East Avenue Medical Center, Quezon City
Telefax: (63-2)929-6853 / 929-6919 / 929-6827 Tel: (63-2)929-6887 / 929-6923
Email: doh_hems@yahoo.com

RAPID HEALTH ASSESSMENT

Event Title: _____″Typhoon JUAN”______
(This form shall be filled-out and submitted by the HEMS Coordinator to the DOH-HEMS within 24 hours upon occurrence of a major health emergency
or disaster, except for mass casualty incidents and outbreaks, for which Form 3-B and Form 3-C shall be used respectively.)

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: 10:00 PM Region: 3 Province: Tarlac Municipality/City: Tarlac
10-23-10
B. Magnitude of Event
Municipality/ Number Affected Evacuation Centers
Province
City Families Individuals No. of EC No. of Families in EC No. of Indiv. in EC
Paniqui
Bacau Evacuation Ctr
Tarlac (Salomague 260 816 816
(260)
Sitio Bacau)
Paniqui (Pob.
Pob.South Central
Norte Sitio 5 22 22
ES (5)
Maligaya)
Paniqui (Pob.
Pob.South Central
Norte Sitio 9 47 47
ES (9)
Basio)
Paniqui (San San Isidro Evac Ctr
352 1,478 1,478
Isidro ) (352)
Paniqui (Canan) 135 461 Canan Elem Sch 461
Paniqui (Aduas) 26 65 Aduas Elem Sch (26) 65
Paniqui (Apulid) 92 368 Apulid Evac Ctr (92) 368
Moncada Calapan Evac.
80 200 200
(Calapan) Center (80)
C. Health Consequences
Total no. of ill / injured Total No.
Total No. (excluding those who have died)
Province Municipality/ City of
of Deaths Admitted then Not
Admitted
Discharged Admitted Missing
Tarlac none none none none none

D. Health Facilities in the Affected Areas

DOH Hospital/s: Fully Functional Partly Functional Totally Non-Functional Remarks:
LGU Hospital/s: Fully Functional Partly Functional Totally Non-Functional Remarks:
Pvt. Hospital/s: Fully Functional Partly Functional Totally Non-Functional Remarks:
RHU/Health Ctr: Fully Functional Partly Functional Totally Non-Functional Remarks:
BHS: Fully Functional Partly Functional Totally Non-Functional Remarks:
Other: ________ Fully Functional Partly Functional Totally Non-Functional Remarks:
E. Lifelines in the Affected Areas
Communication Fully Functional Partly Functional Totally Non-Functional Remarks:
Electric Power Fully Functional Partly Functional Totally Non-Functional Remarks:
Water Fully Functional Partly Functional Totally Non-Functional Remarks:
Roads/Bridges Fully Functional Partly Functional Totally Non-Functional Remarks:
Other: ________ Fully Functional Partly Functional Totally Non-Functional Remarks:
F. Status of Essential Drugs and Supplies in the Affected Areas
No. of Cases No. of Days Remarks
Stock Level Good For:

G. Actions Taken
1. Paniqui RHU and PHO staff visited the evacuation centers gave medical assistance
2. SPEED technology to be implemented
3. LGU’s distributed relief goods to evacuees.
4.
5.
H. Problems Encountered
1. No medicines for infants and children ( drops and syrup )
2.
3.
4.
5.
I. Recommendations
1.
2.
3.
4.
5.
Prepared and Submitted by:
Date Prepared: Oct. 23, 2010 Mobile No.: 09282463684
Signature: Landline: (045)9825163
Printed Name: Luz P. Lopez, RN, MSN Fax No.: (045)9825163
Designation/Office: Provincial DOH – Representative / PHTO - Tarlac Email: phto_tarlac@msn.com