Form 1

General Information About the Hospital

Instructions:
1. This form should be completed by the hospital, preferably by the Disaster Risk Reduction Management in Health
Committee before the evaluation.
2. If necessary, you may photocopy this form or print additional copies from the electronic copy provided
3. You may delete some department services which are not applicable in your hospital as indicated in number 16.
Hospital treatment and operating capacity
4. Indicate the year when this form was accomplished
 GENERAL INFORMATION ABOUT THE HOSPITAL

1. Name of the Hospital:..............................................................................................................................................................................

2. Ownership:______________ ( Government, Private)
3. Class: __________________ (DOH, Military, Provincial, District, City, Municipal, University, etc.)
4. Address: ...................................................................................................................................................................................................
5. Hospital Contact Number:
6. Hospital website:___________________ Official email address: _____________________
7. Names of Hospital Senior Managers (e.g. Medical Director, Chief of Clinics, Chief Nurse, Chief Administrative Officer, Chief of
Finance):
8. Names and contact details of hospital emergency/disaster managers (e.g. chair of disaster risk reduction management committee,
coordinator, manager of security/fire services)
9. Total number of personnel: ..................................................................................................................................................................... … ..
a. Number of clinical staff (e.g. physicians, nurses, medical technologists)..................................
b. Number of nonclinical staff (e.g. executive management, administration, engineers, information technology)
10. Service Capability:____________ ( Level I, II, III)
11. Total number of beds: …………………………………………
12. Average bed occupancy rate (in normal situations): ..................................................................... ………………………………………. .
13. General description of the hospital: e.g. institution to which it belongs (e.g.department, private entity, university), type of establishment
(e.g. tertiary referral hospital, specialized services), role in the network of health services, role in emergencies and disasters, type of
structure, total population served, catchment area (routine services/emergencies and disasters) etc
14. Physical distribution:
List and briefly describe the buildings in the hospital including building name/number and corresponding number of storey. Provide maps
and diagrams of the hospital site and the local setting, including the physical distribution of the services, in the box below. Use additional
pages, if necessary.
15. Geographic Description
A. This describes the hospital location in the area.
a. Total land area
b. Characteristic of location of hospital ( e.g. coastal area, low lying area, landslide prone, mountainous terrain etc.)
c. Location/ distance in kilometers/ meters in relation to active fault line
d. Location/ distance in kilometers/ meters from the sea, river bank, creeks, major highway, railroad
e. Location/ distance in kilometers/ meters in relation to hazardous elements such as oil depot, industrial establishment,
military camps etc.
B. Provide maps for each of the hazard present in the location and catchment area

16. Hospital treatment and operating capacity: Indicate the total number of beds and staff for daily routine services, and additional
capacities to expand services in emergencies and disasters to obtain the maximum hospital capac ity, according to the hospital’s
organization (by department or specialized services). The number of staff available can be used for responding to Module 4 Item 132: Staff
availability.
A. EMERGENCY DEPARTMENT

Department or service Routine Maximum hospital Planned / Standard Actual number of available staff Observations
capacity capacity for emergen- number of staff
(number of cies/disasters Regular Out Contractual
beds) (number of beds) sourced
Triage Area
General Surgery
Trauma and Burn Surgery
Orthopedic Surgery
Neurosurgery
Medicine
Pediatrics
Obstetrics & Gynecology
Ophthalmology
Otorhinolaryngology
Minor Operating Room
Emergency Medicine
Resuscitation Area
Toxicology / Poison Control Unit
Isolation Room
Decontamination Room
Others, please specify whichever
is applicable to your hospital.
E.g.: Animal bite
: Ambulatory Care
: Violence Against
Women & Children
Desk (VAWC)

Total
B. OUT-PATIENT DEPARTMENT

Routine Maximum hospital Planned / Actual number of available staff Observations

capacity capacity for Standard
Department or service (number emergencies/disast
number of Regular Out Contractual
of beds) ers (number of sourced
staff
beds)
General Surgery
Minor Operating Room
Medicine
Pediatrics
Obstetrics and
Gynecology
Ophthalmology
Otorhinolaryngology
Family & Community Medicine
Physical Therapy & Rehabilitation
Dental Unit
Public Health Unit
Acute Psychiatric Unit
Dermatology
TB-DOTS Clinic
Specialty Clinic, specify
- Heart Clinic
- Asthma Clinic
- Diabetic Clinic
Others, specify whichever is applicable
to your hospital:
- Drug Counselling Clinic - HACT Clinic
Others, specify
Total
C. OPERATING THEATRES

Department or service Number of operating Maximum number of theatres Observations

of hospital (for emergencies/
theaters - Routine
disasters)
Septic surgery
Elective surgery
Paediatrics surgery
Thoracic Cardiovascular Surgery

Orthopedic surgery

Plastic and Reconstructive Surgery

Obstetrics and Gynecologic Surgery

Minimally Invasive Surgery

Urology

Surgical Oncology

Emergency surgery
Opthalmologic surgery

Otorhinolaryngology

Neurosurgery

Others, specify

Total
D. DEPARTMENT OF SURGERY

Department or service Routine Maximum Planned / Standard Actual number of available staff Observations
capacity hospital capacity
number of staff
(number of for emergencies/
beds) disasters (number
Regular Out Con
of beds)
source Trac
Tual

General surgery
Trauma and Critical Care
Surgery
Minimally Invasive Surgery
( Laparosopic Surgery)
Pediatric Surgery
Orthopedics
Urology
Neurosurgery
Plastic & Reconstructive
surgery
Thoracic Cardiovascular
surgery
Burn Unit
Surgical Oncology
Others, specify

Total
E. INTERNAL MEDICINE

Department or service Routine Maximum hospital Planned / Actual number of available staff Observations
capacity capacity for Standard
(number of emergencies/disast number of staff
beds) ers (number of Regular Outsourced Contractual
beds)
General medicine
Critical Care
Cardiology
Pulmonology
Infectious Disease
Neurology
Endocrinology
Hematology
Gastroenterology
Allergy /Immunology
Rheumatology
Nephrology and Dialysis
Unit
Oncology
Geriatric Unit
Stroke Unit
Others, specify

Total
F. INTENSIVE CARE UNIT (ICU)

Department or Routine capacity Maximum hospital Planned / Standard Actual number of available staff Observations
service (number of beds) capacity for emergen- number of staff
cies/disasters (number
of beds) Regu Out Cont
lar source ractual
General intensive
care
General
intermediate care
Cardiovascular
ICU
Pediatrics ICU
Neonatal Intensive
Care Unit
Burns ICU
Infectious ICU
a. Adult
b. OB and
Gynecology
c. Pediatrics

High Immuno-
suppression
Care Unit
(HICU)
Others please
specify

Total

G. DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

 Department or Routine capacity Maximum hospital Planned / Standard Actual number of available Observations
service (number of beds) capacity for emergen- number of staff staff
cies/disasters (number
of beds) Regu Out Contrac
lar tual
source
Labor Room
Delivery Room
Gynecological
Oncology
Ultrasound in OB-
Gyne
Perinatology

Reproductive
Endocrinology and
Infertility
Female Pelvic
medicine and
reconstructive
surgery (female
urology)
Family planning

Pediatric and
Adolescent
gynecology
Menopausal and
geriatric
gynecology
Advanced
laparoscopic
surgery
Others, specify

Total
H. DEPARTMENT OF OPHTHALMOLOGY & OTORHINOLARYNGOLOGY

Department, unit or service Planned / Standard Actual number of available staff Observations
number of staff Regular Outsource Contractual

OPHTHALMOLOGY (please
specify available services)

OTORHINOLARYNGOLOGY (please
specify available services)

TOTAL

I. DEPARTMENT OF ANESTHESIA

Department, unit or service Planned / Standard number of Actual number of available staff Observations
staff
Regular Outsource Contrac
tual

Anesthesiologist
Post Anesthesia Care Unit (PACU)
- Nurses
- Anesthesia Technician

TOTAL

J. CLINICAL AND NON-CLINICAL SUPPORT SERVICES

Department, unit or service Planned / Standard Actual number of available staff Observations / Remarks
 number of staff Regular Outsource Contractual
Radiology services - X Rays, CT scan, MRI
Blood bank services
Laboratory Services

Pharmacy
Medical engineering and maintenance
Building/critical systems engineering and maintenance
Security
Admitting and Information Section
Cashier
PhilHealth and Billing Section
Accounting
Human Resource
Dietary Section
Medical Social Service
Linen and Laundry
Central Sterilization and Supply Unit
Housekeeping
Motorpool
Engineering and Maintenance
Waste Management
Procurement
Materials/Inventory Management
Research / Clinical Trial Unit
Mortuary
Others, specify. (Use separate sheet)
TOTAL
K. EMERGENCY AND DISASTER OPERATIONS (may be taken from the above staff)

Department, unit or service Planned / Standard Actual number of available staff Observations
 number of staff Regular Outsource Contractual
Hospital emergency/ disaster operations/
incident management (command, control,
coordination)
Incident Commander

Public Information Officer

Safety Officer/s

Security Officer/s

Liaison officer/s

Operations
- Triage Team
- Treatment Team: Red, Yellow, Green
- Transport / Ambulance Team
- Search and Rescue team

Planning Officer/s

Logisticians
Administration
- Human resource
- others, specify

Finance Officer/s

Communications and information officers

Emergency Response Team
Mortuary
Others, specify
- Medical Junior Interns
- Medical Senior Interns
- Med. Tech. Interns
- Rad. Tech. Interns
Total

17. Areas likely to increase operating capacity

Indicate the characteristics of the locations, areas and spaces that can be used to increase hospital capacity in case of emergencies or
disasters. Specify square metres, available critical systems and any other information that can be used to evaluate the suitability for
expanding space and capacity for hospital medical and other services in emergencies and disasters. Include access, security and critical
services, such as water, power, communications, waste management, heating, ventilation and air-conditioning.

Locations/areas Area m2 Water Supply Electricity/ power Telephone/ Observations

communications
Yes No Yes No Yes No

Ex. Conference
Room/ gym,
basketball court,
parking area and
other open areas
etc.

Locations/areas Area m2 Waste management Heating, Other Observations

ventilation and air-
conditioning
Yes No Yes No Yes No
 Note: Specify the adaptability of use in each space (hospitalization, triage, ambulatory care, observation, staff welfare areas etc.).

18. Hospital Statistics (last 3-5 years upon filling up the form; insert gra[h)
i. Leading causes of morbidity
ii. Leading causes of mortality
iii. Leading causes of consultation ER/OPD
iv. Leading causes of admission
19. Other health facilities within its catchment areas:

a. Other hospitals within the catchment areas. (LGU owned and Private)
Name of Hospital Address Ownership Class Service Capability
(Gov/Pri) (General/Specialty) Level 1 Level 2 Level 3

b. Other health facilities within the catchment areas, regardless of numbers: (LGU owned and Private)

Type of Health Facilities Yes No

Lying in clinics, birthing clinics
Laboratories
Blood Banks
Halfway homes
Dialysis clinics
Health centers
Hospice/Palliative Care
Others:
20. Prior Emergencies and Disasters (include name of the disaster and lessons learned):
..............................................................................................................................................................................................................................

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21. Relevant Hospital Issuances regarding DRRM-H. Enumerate/ List down applicable hospital issuances regarding DRRM-H

22. Logistics for ERT (If Hospital is Identified as Responding)

Item Quantity Buffer Stock

23. Operation Center (4Cs) checklist

Command
Control
Coordination
Name/signature (Chairperson/Head, Hospital Emergency/Disaster Management
Committee) .........................................................................................................................................................