Box 5. Sample form for rapid health assessment in complex emergencies

Area: __________________________ Surrounding towns: __________

Date: _________________ Assessor: ___________________________

Background

Total population - current: ____________________ pre-war: ________

Age and sex distribution:

· population under five years
· other vulnerable groups?

Weather - current: _______ projected: ___________________________

Who is in charge?______________________

Food and agriculture

What are people eating now?______________________

Source(s) of food: ______________________________

Date of last air drop:__________________________

How is air drop, humanitarian aid distributed? ____________________

Does it reach those most in need? _____________________

Market availability (and prices), include black market if possible: _____________
_________________________________________________________________
_________________________________________________________________

Visual assessment of livestock: ________________________________________

Assessment of cooking fuel: __________________________________________

Any seeds available for planting: _______________________________________

Overall assessment of food availability and needs - include timeframe for seeds, etc.

Health and nutrition

Who is in charge?___________________________

What health services exist?____________________

Assessment of damage to health infrastructure:

What public health programmes (vaccination, etc.) currently operate?

Assessment of recent mortality (rates and causes):
__________________________________________________________________

Assessment of recent morbidity (rates and causes):
__________________________________________________________________

Evidence of epidemics: _______________________________________________

(specifically check for measles, hepatitis, diarrhoea)

Current staff: _________________________________

Current drug supplies:___________________________

Current medical supplies: ________________________

Evidence of malnutrition: ________________________

Evidence of micronutrient deficiencies: _____________

Particularly vulnerable groups: ____________________

Overall health assessment - include priorities for assistance:

Water and sanitation

Who is in charge? ____________________________

Normal sources of water: ___________________

Current sources - for drinking: ___________________

for washing, etc.: ____________________________

Estimates of current quantities provided: ____________

Is water tested or treated in any way? ___________

If so, how? ___________________________________

Assessment of damage to water system: ___________________

Assessment of damage to sewer system: ___________________

Changes in water supply expected due to seasonal variation: _________________

Assessment of solid waste disposal: _________________

Problems with rat control:_________________________

Overall assessment: water supplies are adequate or inadequate; safe or unsafe?

Priorities for assistance: _______________________________________

Shelter and household function

Who is in charge? _____________________________________

Assessment of damage to housing: ________________________

Availability of construction materials, plastic, etc.: _____________

What type of clothing are people wearing?__________________

Availability of blankets, sleeping bags, etc.: _________________

Impact of upcoming weather or season: __________________

Logistics and security

Who is in charge?_____________________________________

Possible routes for humanitarian assistance: ______________

Assessment of roads and bridges, etc.: _________________

Availability of local storage facilities: _______________

Security___________________________________________

- checkpoints:_____________________________

- local security: ____________________________

Overall assessment: ______________________

Overall: Top priorities, constraints, etc.