ESR Verification Form Revise

Epidemiology Bureau Date of Release
Event-based Surveillance and Response (ESR) (Date)

Tel: (02) 651-7800 loc 2929
E-mail: esr.central2@gmail.com
This document is distributed only to limited number of DOH, CHD and concerned agency staff for information of events which may have national/ international
implications. Please observe responsible information sharing.
Document Type
Verification report Follow-up report no.: Code: yyyy-mm-no
I. DETECTION
Source of information:
Date detected: mm/dd/yyyy
R/LESU
Time detected: 00:00 AM/PM Internet/Media link
Others specify
II. FILTER AND VERIFICATION

Type of health event: If outbreak, was there an official declaration?
Date of verification: Yes No
Suspect Confirmed If yes, who declared it?
mm/dd/yyyy
Clustering LGU CHD-RESU DOH-EB
Time of verification: Increasing
Others specify
00:00 AM/PM Outbreak Others

specify For LGU declared outbreak,
was it validated by RESU? Yes No
Date of declaration: mm/dd/yyyy
a. Description of health event

Title of health event:
Location of health event: Region
Province/PHI
Municipality
Barangay
Name of Facility/Others
Initial/previously reported Initial/previously
Start date: mm/dd/yyyy no. of cases: reported no. of deaths:
Added Subtracted Added Subtracted

Latest onset: mm/dd/yyyy Total no. of cases: Total no. of deaths:
b. Health status (indicate counts of c. Profile of cases (indicate counts of case/s) d. Profile of deaths (indicate counts of death/s)
case/s)
Admitted: Sex: Age/Age range: Sex: Age/Age range:
RHU/OPD consulted: Male: Min.: Male: Min.:
No consultation: Female: Max.: Female: Max.:

For verification: Unknown: Median: Unknown: Median:
e. Summary of the health event (Describe what happened, common signs and symptoms, diagnosis, and the timeline of events, and distribution of cases and deaths if
multiple locations are affected) [Note: list summary in bullets]
DOH-EB-AEHMD-QMOP-03-Form2 Rev.6
f. Outcome (indicate counts Recovered
of case/s) Active Died For verification
g. Laboratory details Was there a procedure done?
(fill up table below if laboratory examination is done) Yes No For verification
Source No.of No.of No.of
Etiologic
(human/animal Type of cases/ positive negative
Type of Specimen agent/pathogen
/environment Examination done samples cases/ cases/
isolated/detected tested samples samples
etc.)
..add rows as needed

III. ASSESSMENT
a. Status of Health Event Open Closed Date closed: mm/dd/yyyy

b. Level of concern (Please select criteria based on the assessment)
Public Health Event of Local Concern (PHELC)
The health event is confined in a specific geographical location (barangay/cities/municipalities)
The number and severity of cases, deaths, and affected population are higher than expected but within the healthcare system capacity
The health event may involve diseases with existing guidelines for the implementation of preventive and/or control measures to
manage the event
Public Health Event of Regional Concern (PHERC)
The health event has potential to spread to other provinces/Highly urbanized Cities/Independent Component Cities
The number and severity of cases, deaths, and affected population are higher than expected and/or cases are continuously increasing despite
response activities conducted
The health event requires technical assistance from the regional level in the conduct of epidemiological investigation and/or conduct of control
measures
Public Health Event of National Concern (PHENC)
The health event has potential characteristics to cross boundaries or borders (regions or other countries)
Novel health event
The health event involved vulnerable population (e.g. children, pregnant, elders, healthcare workers) from two or more regions
The health event may require national level attention, resources and immediate implementation of control measures due to either of the following:
Has attracted public, media or political interest

The epidemic transmission route is new or unusual
Epidemics associated with health service failure or linked to breakdown in standards of health care delivery such as the following but
not limited to infection control failure or systemic immunization failure
Public Health Event of International Concern (PHEIC)
Health event formally declared by the World Health Organization (WHO)
d. Assistance needed (please specify request)
Category Yes/ Details/Description Remarks
No
1. Technical support for surveillance
2. Human resource
3. Medicines/Medical supplies
4. Laboratory supplies/logistics
5. Health promotion materials
6. Field/Epidemiologic investigation
7. Others
IV. RESPONSE
Status
Specific Actions taken/Planned
Response Office/Agency Date started (pending/ongoing/
activities
done)
1. Case management
2. Laboratory confirmation
3.Field/Epidemiologic
investigation*
4. Program
management/counter measures
5. Health education and

promotion
6. Response coordination
mechanism
7. Others
..add rows as needed
*Level of ESU who conducted epidemiologic investigation
(select all that applies) MESU CESU PESU RESU EB
V. REPORT GENERATION
Name (s) of source(s) of information
Who has been informed?
Prepared by: Reviewed/Noted by: Approved by:
Signature Signature Signature
Name Name Name
Designation/Position Designation/Position Designation/Position
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
DISCLAIMER: Information indicated in this report may change upon further validation or investigation made by the epidemiology and surveillance units and other concerned agencies.

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Epidemiology Bureau Date of Release

Event-based Surveillance and Response (ESR) (Date)

II. FILTER AND VERIFICATION

00:00 AM/PM Outbreak Others

Date of declaration: mm/dd/yyyy

a. Description of health event

Added Subtracted Added Subtracted

Admitted: Sex: Age/Age range: Sex: Age/Age range:

RHU/OPD consulted: Male: Min.: Male: Min.:

No consultation: Female: Max.: Female: Max.:

..add rows as needed

a. Status of Health Event Open Closed Date closed: mm/dd/yyyy

Has attracted public, media or political interest

5. Health education and

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