Esr Template

Provincial Health Office-Public Health Verification
Epidemiology and Disease Surveillance Unit Form

Event-based Surveillance and Response (ESR)
E-mail: [email protected] Date of this Report
Classified Document:
Code: YYYY-MM-NNN
This document is distributed only to limited number of DOH and selected NGO staff in order to improve common awareness on reports and rumours of
events which may have national/ international implications. Please send new or additional information on this or other public health events.
Document Status INTERNAL
Type of Internal Document If report is Verified, FYI or Discard

1 Report date and time Date this health event was first reported to Surveillance Team
2 Verification date and time Date this health event was confirmed/verified by health authority
3 Type of Health Event Check what is applicable:
Suspect Clustering
Outbreak N/A
If an outbreak, who validated? EB-DOH DOH-RESU LGU

Others, specify: Was a report made?
4 Health event What happened? (type of health event reported)
Yes No
5 Location Complete address (number, Street/Barangay, municipality province) where
the reported event was observed. For multiple location (specify on
description of cases)
6 Start date Date of start of event or date of onset of first case
7 Number of cases Initial number of reported case/s from the event
8 Description of cases Pertains to who were affected (age and sex or nature of work), What are
the common signs and symptoms of cases, when, where
9 Number of deaths Initial number of reported death/s from the event
10 Description of deaths Who were affected (age and sex), from Where? (address of fatalities)
When? (Dates of fatalities) and What are the causes of deaths or
description of symptoms prior to death of cases?
11 Laboratory Examination Is there a procedure done?
Yes None
Specimen collected: Blood/serum CSF
Stool
Others: Pls specify other specimens collected
Type of Examination done: Indicate what type of examination was done
Result: Laboratory findings as to specimen collected from the event
12 IHR Notification decision
questions Is the public health impact serious? Yes No
Is the event unusual or unexpected? Yes No
Is there a significant risk of international spread? Yes No
Is there a significant risk of international travel or Yes No
trade restriction?
Assessment done by: Name of staff who made the assessment

13 Assessment PHELC/ PHERC/ PHENC/ PHEIC
14 Status of health event If the health event is Ongoing, Controlled or Closed
15 Actions taken What was done? By whom? When?
16 Assistance needed Specific assistance needed, if there is any
17 ESRU Action To just continue monitoring or will assistance be provided, etc . . .
18 Remarks Other important information not elsewhere mentioned before
19 Who has been informed? To whom the information have been shared (DOH offices, LHO, WHO and
other stake holders)
20 Source(s) of information Name, Office and contact numbers (landline/cellphone)
DOH-NEC-APHD-QMOP-03-Form2 Rev.4
21 Prepared by
Name and signature of the ESR Officer/Coordinator who prepared the report, designation an
22 Reviewed by: Click here to enter text.

23 Noted by: Name and signature of the supervisor on duty and his contact details^
24 Approved by: Name and signature of RESU Head, Division Chief, Director^
*Public Health Event of Local (L), Regional (R), National (N) Concern
** Public Health Emergency of International Concern (PHEIC); according to WHO-International Health Regulation Definition
***Captured by National ESR Staff
^Entries should be signed prior to release of verification form
DISCLAIMER: Every effort has been made to provide accurate, up-to-date information. However, the knowledge base is dynamic and errors can occur. By using the information
contained in this list, the reader assumes all risks in connection with such use. The EB shall not be held responsible for errors, omissions nor liable for any special,
consequential or exemplary damages resulting, in whole or in part, from any reader's use or reliance upon this material.
DOH-NEC-APHD-QMOP-03-Form2 Rev.4

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Esr Template

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Provincial Health Office-Public Health Verification

Epidemiology and Disease Surveillance Unit Form

Document Status INTERNAL

Type of Internal Document If report is Verified, FYI or Discard

If an outbreak, who validated? EB-DOH DOH-RESU LGU

Assessment done by: Name of staff who made the assessment

22 Reviewed by: Click here to enter text.

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