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ESR Verification Form - Dec2015

This 3 sentence summary provides the key details from the verification form document: The verification form is used by the Epidemiology Bureau Event-based Surveillance and Response team to document the verification of reports and rumors of public health events, including the type of event, location, number of cases and deaths, any laboratory examinations performed, assessment of risk of international spread, actions taken, and approvals from supervisors. The form includes 23 items to capture important information about the reported health event such as the date, descriptions of cases and deaths, notification decisions, status of the event, and who has been informed. Completing the verification form allows the surveillance team to improve common awareness of events that may have national or international implications.

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Sandro Redoble
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477 views

ESR Verification Form - Dec2015

This 3 sentence summary provides the key details from the verification form document: The verification form is used by the Epidemiology Bureau Event-based Surveillance and Response team to document the verification of reports and rumors of public health events, including the type of event, location, number of cases and deaths, any laboratory examinations performed, assessment of risk of international spread, actions taken, and approvals from supervisors. The form includes 23 items to capture important information about the reported health event such as the date, descriptions of cases and deaths, notification decisions, status of the event, and who has been informed. Completing the verification form allows the surveillance team to improve common awareness of events that may have national or international implications.

Uploaded by

Sandro Redoble
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Verification

Form

Epidemiology Bureau
Event-based Surveillance and Response (ESR)
Tel: (02) 651-7800 loc 2929
E-mail: [email protected]

Code: YYYY-MM-NNN

Classified Document:
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


1

Report date and time

Verification date and time

Type of Health Event

Suspect

If report is Verified, FYI or Discard


event was first reported to Surveillance Team

Check what is applicable:

Outbreak

Clustering
If an outbreak, who validated?

EB-DOH

N/A
DOH-RESU

Others, specify:

LGU

Was

a report made?

What happened? (type of health event No


reported)
Yes
Complete address (number, Street/Barangay, municipality province) where the reported event
was observed. For multiple location (specify on description of cases)

Health event

Location

Start date

Number of cases

Initial number of reported case/s from the event

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

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?


Specimen collected:

Yes

Blood/serum

None
Stool

CSF

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?


Is the event unusual or unexpected?
Is there a significant risk of international spread?
Is there a significant risk of international travel or
trade restriction?

Yes
Yes
Yes
Yes

No
No
No
No

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


DOH-NEC-APHD-QMOP-03-Form2 Rev.4

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)

21

Prepared by

Name and signature of the ESR Officer/Coordinator who prepared the report, designation and
his/her contact details

22

Reviewed by:

Name and signature of the Supervisor who reviewed the report, designation and contact
number/s (if any)^

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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