Batticaloa Disaster Health Response Team (BDHeaRT) Visit Details Form

Date: Coordinator Name:

1. Name of the camp Place:
Division:
Name of the person in charge of the camp:
GS in charge Name:
Contact person number (any):

2. Total estimated number of people in the camp:
Children under 5 yrs:
No of unaccompanied children:
(Please fill up the UNICEF form attached)
People above 60 yrs:
Pregnant Woman:

3. Patients seen details (to be discussed with Doctor and written)
1. Total Number of patients seen: _______ (give the number attachment for recording)
2. Categories of the patient (Approx.)
Deep infected wounds _____
LRTI cases _____
Diarrohea _____
Malarial symptoms _____
Chronic Diseases (HT, BA, DM, IHD) _____
Skin Diseases _____
Other Specific ( ) _____
( ) _____

4. Total No. of toilets:
Permanent : _____
Temporary : _____
In working condition:
Permanent : _____
Temporary : _____
Comments:

5. Drinking Water:
Adequate: Yes / No
Chlorination Done: Yes / No
Source of water: Well water /Tank water/
Comments:

6. Other Needs / comments: