Community Health Laison Officer Reporting Form
Date
-
Month
-
Day
Year
Date
Name of Locality
Address 2
Address 3
Parish
Christ Church
Saint George
Saint Michael
Saint Philip
Constituency
St. George North
St. George South
St. Philip North
St. Philip South
St. Philip West
Name Of Occupier
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Mobile Number
-
Area Code
Phone Number
Email Address
example@example.com
Does the ministry of health and wellness have your permission to use your information to contact you?
*
YES
NO
Type of Premises
Residence
Church
Vacant Lot
School
Shop
Mini-mart
Squatter
Restaurant
Food Business
Commercial Residence
Apartment
Housing Unit
Other
Is the Property Owned?
Yes
No
If No State Name of Owner.
First Name
Last Name
Landline number of Owner
-
Area Code
Phone Number
Mobile Number
-
Area Code
Phone Number
Type of Structure
Wall
Wood & Wall
Wood
Multi Family
Prefab (Wood)
Prefab (Wall)
State of Building
Good
Fair
Other
Number of Bedrooms
Number of Occupants
Type of Toilet Facilities
WC (Water Closet)
ESP (Environmentally Sanitary Pit)
UIC (Used in Common)
E.P (Environmental Pit)
NONE
Water Source
BWA
Other
Type of Water Storage Facilities
Buckets
Bottles
Tanks (Underground)
Tanks (Surface)
Tanks (Overhead)
Pans
Nil
General Health Status of Persons In Household and National Registration Number
FN
MN
LN
NRN
Age
Sex
Diabetes
Cardiovascular
Chronic Respiratory Diseases
Intellectual and Developmental Disabilities
Mental Disability
Other
1
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
2
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
3
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
4
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
5
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
6
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
7
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
8
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
9
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
10
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
11
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
12
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
13
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
14
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
15
Male
Female
Type 1
Type 2
Gestational
Diabetes Insipidus
N/A
Heart Failure
Coronary Artery Disease
Cardiomyopathy
Irregular Heart beat
Heart Attack
N/A
Asthma
Sleep Apnea
Chronic Obstructive Pulmonary Disease
N/A
Down Syndrome
Cerebral Palsy
ADHD
Autism
Visual Impairment
Deafness
Blindness
N/A
YES
NO
Do your receive assistance?
YES
NO
What is the State entity from which assistance was recieved?
Child Care Board
Environmental Health Department
National Assistance Board
Rural Development Commission
Welfare Department
Elder Affairs
Environmental Concerns?
Communal garbage collection
Derelict House
Derelict Vehicle
Flood Prone
Illegal Dumping
Infestation (Bed-Bugs)
Infestation (Mosquitoes)
Infestation (Rodents)
Storm water well
Other
Community Concerns
No Electricity
No Internet
No Income
Other
Water Quality ?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Water Service ?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Notes (General Notes)
Covid-19 Awareness
*
Hand-washing explained and demonstrated
Sanitizing processes explained
Physical distancing explained
Respiratory Hygiene explained
Use of masks explained
Advised of voluntary testing administered at Polyclinic
Other
Name Of Officer
*
Mahalia Ashby
Pamela Brathwaite-Went
Elson Farley
Monique Hinds
Margaret Lorde
Karlson Lovell
Deana Peters
Telisa Rogers
Submit
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