R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

FORM I
Initial Report on (disaster incident)
To be submitted within 2 hours after the flash report
____________________________________________

Origin of Report:

1. Profile of the Incident:

• What : ____________________________________________________
(Type of disaster)

• When : ____________________________________________________
(Date and time of occurrence)

• Where : ____________________________________________________
(Exact locations)

• Why : ____________________________________________________
(Probable cause of the incident)

• Who : ____________________________________________________
(Affected population (________ children_____________adults
(women)
(Responding local agencies in the area)

• How : ____________________________________________________
(How was the initial local response carried out?)

 Is there a need for:

Search and rescue assistance? _____ Yes ______ No

Evacuation? ________ Yes ________ No

_____________________
Signed: Local DCC Chairman
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

Form II

Rapid Damage and Needs Assessment Checklist

(To be submitted within 12 hours upon occurrence of disaster)

A. Profile of the Disaster

1. Type of disaster/emergency ____________________________________
2. Date and time of occurrence ____________________________________
3. Areas Affected __________________________________________________
(barangays, municipalities/cities, provinces, regions)
4. Sources of reports ______________________________________________
5. Date and time of reports ________________________________________

B. Initial Effects:
1. Affected Population: ___________Families _____________Persons
2. Displaced Population: ___________Families _____________Persons
Infants - 0-1 year old _______________________
Children - 2-12 years old _____________________
Adolescent - 13-17 years old ____________________
Adults (women) - 18 and above ______________________

3. Casualties: Location Number Cause

Dead __________________ ________ _________________
Injured _________________ ________ _________________
Missing __________________ ________ _________________

C. Initial Needs Assessment

1. Search and Rescue

1.1 Exact locations __________________________________________

(barangays, municipalities/cities, provinces, regions)
1.2 Approximate number of missing _____children ______adults
(women)

1.3 Response Status __________________________________________

(local SAR and resources deployed by DCCs)
1.4 Unmet needs for which additional SAR resources are
requested? _______________________________________________
(teams, rescue boats, heavy equipment, expertise)
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

2. Evacuation
2.1 Exact locations ___________________________________________
(region, province, municipality, city, barangay)
2.2 Approximate number of people to be evacuated
____infants,_______children _______adults (women)

2.3 Response status __________________________________________

(number of people evacuated by local DCCs)
2.4 Unmet needs for which additional evacuation assistance is
requested ? _______________________________________________
2.5 Names of e vacuation centers ____________________________
___________________________________________________________
2.6 Number of families or persons housed in evacuation
centers who are in need of assistance ______________families
______________persons
(______infants, ______children _______adults (women)
2.7 Daily requirements of affected families in the evacuation
center ____________________________________________________
2.8 Are there enough latrines in the evacuation centers? ______

3. M edical Health
3.1 Exact locations_____________________________________________
(barangays, municipalities/cities, provinces regions)
3.2 Number of injured _________________________________________
______infants______ children _______adults (women)
3.3 Displaced families or persons who are in need of medical
attention _____________families _______________ persons
_______infants _______children _______adults (women)
3.4 Response status ___________________________________________
(condition of medical facilities)
3.5 Unmet needs ______________________________________________
(medicines, medical supplies & teams required
from national sources)
3.6 What specific effects has the situation had on health of
survivors?_________________________________________________
3.7 Are there any health–related cases prevailing in the area.?
If so, what health care facilities exist where and what?____
___________________________________________________________
3.8 Who is in charge of emergency health and medical services
in the area?_______________________________________________
3.9 Are there health workers in the community assessing the
health and nutritional status of affected children in the
e vacuation centers? ______________________________________
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

4. Shelter and Clothing

4.1 Exact locations __________________________________________
(barangays, municipalities/cities, provinces and regions)
Number of people requiring shelter and clothing__________
___________M ale _____________ female
_______infants _______children _____adults (women)
Response Status ________________________________________
(number of people being provided with shelter and
clothing by local DCCs)
4.4 Unmet needs ___________________________________________
(number of people needing assistance and specify type of
assistance required (tents, blankets, mosquito nets and
clothing )

5. Food
5.1 Exact locations __________________________________________
(barangays, municipalities/cities, provinces, regions)
5.2 Total number of people requiring food ____________________
_______infants, _______children ____adults (women)
5.3 Response Status _______________________________________
(number of people provided with food by the local DCCs)
______infants _________children ______adults (women)
5.4 Unmet needs ___________________________________________
(number of people for whom external supplies of food are
requested)
5.5 Are food resources and local buffer stocks available ?
_______________________________________________________
5.6 Is food assistance equally distributed? _________________
5.7 Are the children being provided with food assistance
according to their needs?_______________________________
5.8 Are prime commodities locally available? ____yes _____no

6. W ater
6.1 Exact locations ________________________________________
(barangays municipalities,/cities, province, regions)
6.2 Number of people without potable water _________________
_________children _________adults)
6.3 Response status________________________________________
(number of people being supplied with potable water by
the local DCCs; condition of supply system and repair
status; availability of surface water)
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

6.4 Unmet needs __________________________________________

(Number of people whom external supplies of water
requested and need for treatment supplies, container
and trucks)
6.5 Are there any arrangement for water storage & distribution
system in the area ? _______________________
6.6 Is there water shortage? ___________yes ______________no
_____date______time ____________probable cause
6.7 Is it widespread or concentrated in one area? __yes ___no
6.8 Are there alternate sources of water? ____yes ____ no
If yes, specify _________________________________________
6.9 Did the service providers took immediate repairs? __yes
___no. If yes, how long will it take to restore the
systems? number of days __________________________

7. Environmental Sanitation
7.1 Are there enough latrines for sanitary disposal of feces
that are away from water sources, cooking and eating
areas? _________________________________________________
7.2 Are there washing facilities and adequate cleaning materials?
_____________________________________________

8. Restoration of Lifeline Systems

8.1 Exact Locations_______________________________________
(barangays, municipalities/cities, provinces, regions)
8.2 Conditions of lifeline systems __________________________
(Roads, bridges, railways, power supplies and communication
systems )
8.3 Is it operational or non operational? If not what are the
emergency measures undertaken by the service providers?
_______________________________________________________
8.4 Response Status _______________________________________
8.5 Unmet Needs _________________________________________
(list of personnel, supplies and equipment requested
from external sources)
8.6 Was there power interruption? ______yes __________no
_______date _______ time and ______probable cause
8.7 Is it widespread or concentrated in one area?___yes___no
8.8 Are there electric posts toppled down? ____yes ______no
8.9 How long will it take before the service is restored?
Number of days _______________________________________
8.10 What are the actions taken by the servicing companies?
_______________________________________________________
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

9. Children’s Educational Needs

9.1 Are there school buildings damaged? ______yes _____no
If yes, how many children are affected? ____________boys
___________girls
9.2 What is the extent of disruption caused by the emergency
situation? ______________________________________________
9.3 How many children are in need of primary education?
______________boys ________________girls

9.4 Location of the target groups ___________________________

9.5 Le vel of formal and non-formal education of children

_______________________________________________________
9.6 Instructional materials available ________________________
_______________________________________________________
9.7 Existing physical facilities that could be used for non-
formal schooling _______________________________________

E. Local Initial Actions

1. Emergency Responders involved_________________________________

2. Assets Deployed________________________________________________
3. Number of Families/Persons Initially Served ____________ families
_________ persons ( ____infants ______children _______adults)
4. Extent of Local Assistance _____________________________________

Signed : ________________
Local DCC Chairman
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

Form III

DAM AGE ASSESSMENT FORM

(to be submitted within 24 hours upon occurrence of disaster

A . Profile of the Disaster

1. Type of Disaster / Emergency ______________________________

2. Date and Time of Occurrence ______________________________
3. Source of Report __________________________________________
4. Date and Time of Report ___________________________________

B. Summary of the Effects (as of reporting time)

1. Areas Affected
(barangays, cities/ municipalities, provinces, regions)

2. Population Affected (cumulative total)

Families _____________________________________________
Persons _____________________________________________
( no. of children with age ranging from 1-17 years old)

3. Population Displaced (cumulative total)

Families ____________________________________________
Persons ____________________________________________
Infants - 0-1 year old ______________________
Children - 2-12 years old _____________________
Adolescent-13-17 years old ____________________
Adults - 18 and above ______________________

4. Casualties (cumulative total)

Dead
Injured
Missing

5. Damaged Properties (structures)

Breakdown Totally Partially Est Cost

(Number) (Number)

Houses _____ _______ _____________

School Buildings _____ ______ _____________
Hospital _____ ______ _____________
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

Gov’t Offices _____ ______ _____________

Public Markets _____ ______ _____________

Flood Control _____ ______ _____________

(sea walls/dikes/dams/irrigation systems

Commercial Facilities ______ _______ _____________

(factories,/malls/stores/supermarkets)
Others (specify) _____ _______ _____________

6. Damaged Lifelines

6.1 Transportation Facilities

Location Passable/Not passable No. Cost
Roads
National _____ ______ / _______ ____ ____
Provincial _____ ______ / _______ ____ ____
Municipal _____ ______ / _______ ____ ____
City _____ ______ / _______ ____ ____

Barangay _____ ______ / _______ ____ ___

Bridges
Bailey _____ ______ / _______ ____ ____
Concrete _____ ______ / _______ ____ _____
Wooden _____ ______ / _______ ____ _____

Railways _____ ______ / _______ ____ _____

6.2 Communication Facilities

Location Operational/
Non Operational No Cost
PLDT __________ ______________ ____ _____
Bayan Tel ______ _______________ ____ _____
Cell Sites ______ _______________ ____ _____
Radio
repeaters _______ ______________ ____ _____

6.3 Electrical Power

_______ ______________ _____ ______
6.4 W ater Facilities
_______ _______________ _____ ______
 R e p o r t D e v e l o p m e n t W o r k s h o p | ANNEX D

7. Agriculture

7.1 Crops
Areas Damaged Losses
No. of Has) (M etric Tons) (Peso Value)
Rice _________ ___________ ___________
Corn ________ _________ __________

Vegetables ________ _________ ___________

Root crops ________ _________ ___________
Fruit trees ________ _________ ___________
Bananas _________ _________ ___________
Others _________ _________ ___________

7.2 Fisheries
Fishponds _________ __________ ___________
Fishing boats (number ) _________ ___________

7.3 Livestock
Animals No. of Heads Peso value
Farm Animals ___________ _____________
Poultry and Fowls ___________ _____________

C. Local Actions
1. Emergency Responders Involved _________________________
__________________________________________________________
2. Assets Deployed __________________________________________
___________________________________________________________
3. Number of Affected Population Served
Families _______________________________________________
Persons ________________________________________________
4. Number of Displaced Population Served
Families _______________________________________________
Persons _______________________________________________
(________infants, _______children and _______adults)
5. Extent of Local Assistance________________________________
__________________________________________________________

Progress report to follow

____________________
Signed: Local DCC Chairman