Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
SAN SIMON FIRE STATION
Brgy San Agustin, San Simon, Pampanga
EMERGENCY MEDICAL SERVICE
Accomplishment Report
CITY/MUNICIPALITY: ____PROVINCE: ______
Month
Total Patients Status of Patient /Victim
Total
from
TURNOUT Ambulance Type of Beneficiary
Ambulance Treated/ BP Trans to
Name of Medical Facility Expired
Response Taken Hosp
Run
I. EMS Responses
A. Fire Incident UP
NUP
0 Dependents
Civilians
B. Medical Cases UP
NUP
0
Dependents
Civilians
C. Natural Calamities UP
Typhoons NUP
0 Dependents
Civilians
Landslides UP
NUP
0
Dependents
Civilians
Floods UP
NUP
0
Dependents
Civilians
Earthquakes UP
NUP
0
Dependents
Civilians
Others ( Specify) UP
NUP
0
Dependents
Civilians
D. Man Made UP
NUP
0
Dependents
Civilians
E. Vehicular Accidents UP
NUP
0
Dependents
Civilians
TOTAL RESPONSES/ TURN OUT 0
TOTAL NO OF PATIENTS (FROM
RESPONSES)
F. Other Responses / Special Activities UP
NUP
e.g. (Medical Standby, Medical Transport,
Lectures, Blood Letting, Fire Drill, Tree 0 Dependents
Planting, PFT, *Medical Examination for
Recruitment, Promotion, Trainings, etc)
Civilians
II. Consultations UP
NUP
0
Dependents
Civilians
III. BP Monitoring UP
NUP
0
Dependents
Civilians
*Legend: Summary: Subtotal No. of Beneficiaries UP 0
UP - Uniform Personnel NUP 0
NUP - Non-Uniform Personnel Dependents 0
Trans to Hosp - Transported to Hospital Civilian
Grand Total
Prepared by: Certified by: Noted by:
Ambulance Driver/ Crew Mun. C, Operations Unit Municipal Fire Marshal
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
SAN SIMON FIRE STATION
Brgy San Agustin, San Simon Pampanga
BFP STATION EMS ACCOMPLISHMENT REPORT
Month OF ___
EMERGENCY RESPONSE NON EMERGENCY RESPONSE
EMS Station PATIENTS
RESCUE TOTAL # OF
MEDICAL/TRAUMA VEHICULAR TOTAL # OF FROM
FIRE OPERATIONS/ SPECIAL ACTIVITY BENEFICIARIES CONSULTATION BP MONITORING
CASES ACCIDENTS RESPONSES AMBULANCE
DISASTER OF SA
RUN
TOTAL
Breakdown:
Uniformed Personnel: 0
Non Uniformed Personnel: 0
Dependents: 0
Civilians:
Total:
Prepared by: Certified by: Noted by:
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
SAN SIMON FIRE STATION
Brgy San Agustin, San Simon Pampanga
Month of ________
Time of Departure of Time of Arrival of
Responding Time EMS Call Response
Date of Responding Unit Responding Unit at Nature of EMS Exact Location/
No. EMS Station Received Time (Min) Name of Patient Age
Incidence from Station EMS Scene Incident Address of EMS
Unit
(a) (b) (c) (c-a)
Non-Fire Related Emergency Calls Responded
total
Fire Emergency Calls Responded
Prepared by: Certified by: Noted by:
Ambulance Driver/ Crew Mun. C, Operations Unit Municipal Fire Marshal
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
Month of SEPTEMBER 2018 PERFORMANCE INDICATOR
TOTAL RESPONSES RESPONDED WITHIN 7
RESPONSE NO. OF RESPONSES PERCENTAGE
MINUTES PRESCRIBED RESPONSE TIME
NUMBER OF NON-FIRE
EMERGENCY CALLS NEGATIVE
RESPONDED
NUMBER OF FIRE
RELATED EMERGENCY
CALLS RESPONDED
GRAND TOTAL
Prepared by: Certified by: Noted by:
Ambulance Driver/ Crew Municipal C, Operation Municipal Fire Marshal
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
Month of ________
DEVELOPMENTAL STAGE MALE FEMALE
Infant (0-1 1/2) NEGATIVE
Toddler (1 1/2-3)
Preschool (3-5)
School age (5-12)
Adolescence (12-18)
Young adult (18-40)
Adulthood (40-65)
Late Adulthood (65 & up)
Others *age not identified
TOTAL
Prepared by: Certified by: Noted by:
AMBULANCE DRIVER/ CREW Mun. C, Operations Unit Municipal Fire Marshal
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
REGION 3
DENTAL SERVICE
Accomplishment Report
Month of ________
Hereunder are the Dental Services rendered in this month:
0 UNIFORMED PERSONNEL
Consultation
Oral Prophylaxis
Restoration
Extraction
Prosthodontics
Other surgical procedure (e.g. Odontectomy)
0 NON-UNIFORMED PERSONNEL
Consultation
Oral Prophylaxis
Restoration
Extraction
Prosthodontics
Other surgical procedure (e.g. Odontectomy)
0 DEPENDENTS
Consultation
Oral Prophylaxis
Restoration
Extraction
Prosthodontics
Other surgical procedure (e.g. Odontectomy)
0 CIVILIANS
Consultation
Oral Prophylaxis
Restoration
Extraction
Prosthodontics
Other surgical procedure (e.g. Odontectomy)
No of dental mission / free clinic conducted:
No of beneficiaries (dental mission):
No of FO1 applicants examined:
No of UP examined for promotion:
No of UP examined for training:
UP
NUP
DEPENDENTS
CIVILIAN
GRAND TOTAL :
Prepared by: Certified by:
Ambulance Driver/ Crew Mun. C, Operations Unit
ublic of the Philippines
he Interior and Local Government
U OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
REGION 3
DENTAL SERVICE
complishment Report
Month of ________
this month:
edure (e.g. Odontectomy)
edure (e.g. Odontectomy)
edure (e.g. Odontectomy)
edure (e.g. Odontectomy)
0
0
0
0
0
0
Noted by:
Municipal Fire Marshal
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
EMERGENCY MEDICAL SERVICES
Accomplishment Report
Month of SEPTEMBER 2018
CENSUS OF DISEASES/CASES
RESPIRATORY SYSTEM PTS GASTROINTESTINAL SYSTEM
1 Hyperventilation 1 Acute Gastroenteritis/LBM
2 Common Colds 2 Abdominal Pain
3 Asthma 3 Peptic Ulcer Diseases
4 COPD 4 Esophagus Ulcer
5 Tuberculosis 5 Gastritis
6 Pneumonia 6 Balinitis
7 Suffocation 7 Appendicitis
CARDIOVASCULAR SYSTEM PTS INTEGUMENTARY SYSTEM
1 Hypertension 1 Cellulitis
2 Chest Pain 2 Hypersensitivity Reaction
3 Congenital Heart Disease 3 Wound
4 Heart Attack/Stroke 4 Soft Tissue Swelling
5 Ischemic Heart Disease 5 Burn
6 Heart Failure 6 Boil
7 Carbuncle
8 Insect/cat bite
MUSCULOSKELETAL SYSTEM PTS URINARY SYSTEM
1 Multiple Myoloma 1 UTI
2 Head Injury 2 Cystitis
3 Spinal Injury 3 Chronic Renal Disease
4 Fracture/Dislocation 4 Renal Failure
5 Spinal Cord Injury 5 Renal Stones
6 Sprain 6 End Stage Renal Disease
7 Lower/Upper Extremeties Pain
EENT PTS NEUROLOGICAL SYSTEM
1 Cataract 1 Meningitis
2 Otitis 2 Psychiatric Problem
3 Oral thrush 3 Epilepsy/ Seizure Disorder
4 Post Nasal Drip 4 Migraine/headache
5 Allergic Rhinitis 5 Head Trauma
6 Foreign object obstruction 6 Dizziness
7 Conjunctivitis 7 Disoriented
8 Sinusitis 8 Vertigo
9 Contusion of Eye 9 Headache
10 Eye Irritation 10 Soft Tissue Swelling
ENDOCRINE SYSTEM REPRODUCTIVE SYSTEM
1 Diabetes Mellitus 1 Rupture amniotic sac
2 Chicken Pox 2 Ovarian Cancer
3 Goiter 3 Pregnancy
4 Prostate problem 4 Breast Cancer
5 Increase Blood Sugar 5 Giving Birth
6 Gout 6 Pre-term labor
OTHERS PTS OTHERS
1 Radiation Therapy 9 Hematemesis
2 Systemic Viral Infection 10 Hypoglycemia
3 Chest Pain 11 Hemorrhoid
4 Abscess 12 Convulsion
5 Body weakness 13 Typhoid
6 LOC 14 Hepatitis
7 Alzheimer's Disease 15 Dehydration
8 Hyperurecemia 16 Epistaxis
PTS
PTS
PTS
PTS
PTS
PTS
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
STATUS OF EMERGENCY VEHICLE
Month of ________
STATUS
EMS STATION ADDRESS Tel No No of Personnel No of Vehicle TYPE / BRAND REMARKS
Opnal Non Opnl BER
Prepared by: Certified by: Noted by:
Ambulance Driver/ Crew Mun. C, Operations Unit Municipal Fire Marshal
Health and Emergency Management Division
Accomplishment Report
Month of _______
10 Leading Diseases/Cases
No Disease/Cases Total
1
NEGATIVE
2
` Prepared by: Certified by:
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
SPECIAL ACTIVITY
EMERGENCY MEDICAL SERVICES
Month of _______
EMS STATION DATE
Prepared by:
Ambulance Driver/ Crew
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
SPECIAL ACTIVITY
EMERGENCY MEDICAL SERVICES
Month of _______
No. of Patients/No. of Beneficiaries
SPECIAL ACTIVITY
UP NUP DEP CIV
Negative
Certified by: Noted by:
Mun. C, Operations Unit Municipal Fire Marshal
LEGEND:
DEP- DEPENDENTS
CIV- CIVILIAN
nicipal Fire Marshal
Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION 3
FIRE STATION
(address)
HEMS PERSONNEL PROFILE
Month of SEPTEMBER 2018
Office / Unit: Fire Station
No Rank Complete Name Current Position Eligibility Educational Highest EMT- B TRAINING Nme of With EMS NCII (TESDA)
DOB
Surname Firstname MI Designation Attainment Training YES NO Training Institute YES NO
1
2
3
4
5
6
DENTAL SERVICE
No Rank
Complete Name Current Position Educational Highest EMT- B TRAINING Nme of With EMS NCII (TESDA)
DOB Eligibility
Surname Firstname MI Designation Attainment Training YES NO Training Institute YES NO
Physical
DOCTORS DENTIST Nurse Allied Medical Non-Medical Medical Technologist Pharmacist TOTAL
Therapist
0 0 6 0 0 0 0 0 6
Prepared by:
Certified by: Noted by:
Operations Clerk Mun. C, Operations Unit Municipal Fire Marshal
BFP R3 EMS ISSUES AND RECOMME
PROVINCE ISSUES/PROBLEMS
BULACAN
NUEVA ECIJA
PAMPANGA
Prepared by: Certified by: Noted by:
Ambulance Driver/ Crew Mun. C, Operations Unit Municipal Fire Marshal
R3 EMS ISSUES AND RECOMMENDATIONS
EMS RECOMMENDATIONS/POSSIBLE SOLUTIONS
Municipal Fire Marshal
