FORM I
(r. 2)
REGISTER OF MEDICAL PRACTITIONERS AND DENTISTS
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Full Name
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Address
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Basic Qualification
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Date of Registration
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Additional Qualification
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Date and No. of original Registration
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Remarks
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FORM II
(r. 3)
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
APPLICATION FOR REGISTRATION AS A MEDICAL PRACTITIONERS OR DENTIST
1. Surname (BLOCK LETTERS) ........................................................
2. Other Names (BLOCK LETTERS) .................................................
..........................................................................................................
3. Address ......................................................................................
4. Telephone No. .................................................................
5. Place and Date of Birth ...................................................
6. Nationality ........................................................
7. Degree, Diploma or Licence held (give name of medical school and date qualified)
................................................................................................................
................................................................................................................
................................................................................................................
(Legible certified true photocopies should be supplied)
8. Particulars of Experience (e.g. post held, type of practice in which engaged, country in which the applicant has practised, dates must be clearly stated)
................................................................................................................
................................................................................................................
................................................................................................................
9. Number and Date of Original Registration in Kenya (when applicable)
................................................................................................................
10. Testimonials Covering the Period(s) of Experience ..........................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
(Photocopies should be supplies for record purposes.)
11. What arrangements, if any, have been regarding your employment? .........................
................................................................................................................
................................................................................................................
................................................................................................................
A fee of Sh. 200 is payable for registration. In the case of reinstatement of name to the register under section 8(3)(c) the fee payable is Sh. 100.
Signature of Applicant ......................................................................
Date ....................................................................................................
FORM III
(r. 4)
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
CERTIFICATE OF REGISTRATION AS A MEDICAL PRACTITIONER OR DENTIST
Registration No. .........................
Dr./Mr./Mrs./Miss* ...................................................................................
.................................................................. (full names in BLOCK LETTERS)
has been registered as a Medical/Dental* Practitioner in accordance with the provisions of section 6 of the medical Practitioners and Dentists Act.
Dated this ................................... day .............................., 20 .........
Seal of the Board
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.................................................ChairmanMedical Practitioners and Dentists Board
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.................................................Registrar ofMedical Practitioners and Dentists
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*Delete where not applicable
FORM IV
(r. 5)
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
APPLICATION FOR A LICENCE TO RENDER MEDICAL OR DENTAL SERVICES
1. Surname (BLOCK LETTERS) ...................................................
2. Other Names (BLOCK LETTERS) ............................................
............................................................................................................
3. Address .........................................................................................
4. Place and Date of Birth .................................................................
5. Nationality ......................................................................................
6. Degree, Diploma or Licence held (give name of medical school and date qualified)
................................................................................................................
................................................................................................................
................................................................................................................
(Legible certified true photocopies should be supplied.)
7. Particulars of Experience (e.g. posts held, type of practice in which the applicant has been engaged, countries in which the applicant has practised)
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
8. Testimonials Covering the Period(s) of Experience ..............................
................................................................................................................
................................................................................................................
................................................................................................................
(Photocopies should be supplied for record purposes.)
9. Have any arrangements been made regarding employment? (If so, give details)
................................................................................................................
................................................................................................................
A fee of Sh. 100 is payable for a licence, except for interns under section 11 of the Act.
Signature of the Applicant .......................................................................
Date ............................................................................................................
FORM V
(r. 6)
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
LICENCE TO RENDER MEDICAL FOR DENTAL SERVICES
Licence No. ...........................
Dr./Mr./Mrs./Miss* ..................................................................................................
............................................................................................ (full names in BLOCK LETTERS)
is hereby licensed by the Medical Practitioners and Dentists Board to render medical/dental*services at ..................................................................................................................
(name of approved institution) in accordance with the provisions of section 13 of the Act.
Dated this ....................... day of ............................., 20 .............
........................................................
Director of Medical Services
CONDITIONS OF LICENCE
1. This licence is valid for a period of .........................................................from the date hereof.
2. The licensee is authorized to render medical or dental services, as the case may be, only at the institution mentioned in this licence.
3. ..............................................................................................................................................................................................................................................................................
4. ...........................................................................................................................................................................................................................................................................
5. ........................................................................................................................................................................................................................................................................................
*Delete where not applicable
FORM VI
(r. 7)
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
APPLICATION FOR LICENCE FOR PRIVATE MEDICAL/DENTAL PRACTICE
1. Surname (BLOCK LETTERS) ...................................................
2. Other Names (BLOCK LETTERS) ..............................................
............................................................................................................
3. Address .........................................................................................
4. Place and Date of Birth .................................................................
5. Nationality ......................................................................................
6. Registration No. and Date ..........................................................
7. Particulars of Experience (e.g. posts held and types of practice in which the applicant has been engaged and countries in which the applicant has practised).
Medicine .......................................................................................Surgery ............................................................................................Paediatrics .......................................................................................Obstetrics and Gynaecology ............................................................Others .............................................................................
................................................................................................................
................................................................................................................
8. Do you propose to practice on your own behalf or to be employed whole-time or part-time by a Private Practitioner (give details)?
................................................................................................................
9. What type of practice do you propose to engage in? Specialist/General Practice. If Specialist please specify the disciple ..........................................................................
................................................................................................................
10. Place of Practice (district, city, or town, market, plot number, give details)
................................................................................................................
................................................................................................................
................................................................................................................
11. Is this a New Application or a Renewal? ............................................................A fee of Sh. 500 is payable annually for Specialist Practice.A fee of Sh. 400 is payable annually for General Practice.
Signature of Applicant ......................................................................................
Date .................................................................................................................
FORM VII
(r. 8)
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
LICENCE FOR PRIVATE MEDICAL OR DENTAL PRACTICE
Licence No. ....................................
1. Dr./Mr./Mrs./Miss* .......................................................................
..........................................................................................................
...........................................................................................................
(full names in BLOCK LETTERS) OF ............................................
.................................................... (full address) is hereby licences in accordance with the provisions of section 15 of the Act to engage in private practice on his/her* own behalf as a private medical/dental* practitioner or to be employed whole-time/part-time*, by a private practitioner, Dr./Mr./Mrs/Miss*.................................. (name and address of the employer private practitioner).
2. This licence entitles the holder to engage in General Practice/Specialist Practice* in .................................................................................. (specify discipline).
3. Authorized premises to be used for the purposes of private practice ........................
...........................................................................................................
(detailed particulars and location of authorized premises).
4. This licence shall expire on the last day of .................................., 20 ...............
5. No change of premises is permitted without the authority of the Board.
Dated this ......................................... day of .............................., 20 ...............
..........................................
Registrar ofMedical Practitioners and Dentists
*Delete where not applicable.
FORM VIII
(r. 9)
[L.N. 76/1983, s.2, Corr. No. 26/1983.]
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
APPLICATION FOR RECOGNITION OF SPECIALIST/SUB-SPECIALITY STATUS
1. Surname (BLOCK LETTERS) ..........................................................................
..................................................................................................................................
2. Other names ...................................................................................................
3. Registration No. ...........................................................................
4. Address ............................................................................................
...............................................................................................................
...............................................................................................................
5. Place and date of birth ....................................................................
6. Nationality ...............................................................................
7. Places of practice ..................................................................
8. Degree or Diploma (give name of Medical School and date qualified) ..............
..................................................................................................................................
9. Speciality or sub-speciality in which specialist/sub-specialist status sought (state clearly) ....
..................................................................................................................................
10. (a) Post-graduate qualifications (indicate the discipline, name of institution, country and date qualified) ........................................................................................................................................
...................................................................................................................................
(b) Duration of the course(s) .....................................................................
...................................................................................................................................
11. Number of years of experience after obtaining post-graduate qualifications (indicate the number of years or months, name of institution(s) attended and name of supervisor, whose letter must accompany this application) ..............................................................................................................
...................................................................................................................................
...................................................................................................................................
12. List of publications (if any) ......................................................................
...................................................................................................................................
13. Number of years experience in sub-speciality (indicate clearly number of years or months, name of institution(s) attended and name of supervisor, whose letter must accompany this application) ..................
...................................................................................................................................
...................................................................................................................................
14. I solemnly and sincerely declare that the information given is true.
Dated the .................................................................., 20 ..............
....................................................
Signature of Applicant
FORM IX
(r. 4(1))
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
APPLICATION FOR REGISTRATION OF A PRIVATE MEDICAL INSTITUTION
PART I
(To be completed by the applicant in triplicate)
1. Name and Address of the Proposed Institution (BLOCK LETTERS) ....................
...........................................................................................................
...........................................................................................................
2. Type (State whether Hospital, Nursing Home, Maternity Home, Health Centre, Dispensary, Laboratory, etc) ..............................................................
...........................................................................................................
...........................................................................................................
3. Location and Institution—
(a) Town/Centre/Market* .............................................................
(b) Location .................................................................................
(c) District ...................................................................................
(d) Province ..............................................................................
*Delete where inapplicable.
PART II
(To be completed by the applicant in triplicate)
1. Full Name and Address of the Applicant (BLOCK LETTERS) ..........................
........................................................................................................................
........................................................................................................................
2. State if Applicant is a Director and/or Administrator of the Institution ........................
........................................................................................................................
........................................................................................................................
3. Nationality of the Applicant ......................................................
4. Place and Date of Birth ...........................................................
5. Kenya National Identity Card no. ...............................................
(Attach photocopy)
6. Passport No. (if applicable) ...................................................................
........................................................................................................................
7. Work Permit No. (if applicable) ..............................................................
(Attach documentary evidence — copies only).
PART III
(To be completed by the applicant in triplicate)
Give full names of Directors of the Institution including the following: Nationalities, Passport Numbers, Work Permit Numbers, Kenya National Identity Card Numbers, etc.
(Attach copies of documentary evidence)
(a) ..........................................................................................................
................................................................................................................
................................................................................................................
(b) ...........................................................................................................
..................................................................................................................
....................................................................................................................
(c) ................................................................................................................
........................................................................................................................
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(Use extra space if necessary)
PART IV
(To be completed by the applicant in triplicate)
1. Give full names of Medical or Dental Practitioners who shall be in-charge of patient health care at the proposed institution ............................................................................................
........................................................................................................................
........................................................................................................................
2. (a) Give full details of professional qualification of the person named in paragraph (1) above. Include year and place where obtained.
(b) State work experience of the person named in paragraph (1) above and name institutions where obtained and date.
(c) Attach copies of documentary evidence in each case. (Use extra space if necessary)
........................................................................................................................
........................................................................................................................
........................................................................................................................
3. (a) Give full names and professional qualifications of any other person(s), identified by your institution, to undertake patient health care at the institution (e.g. Clinical Officers, Nurses, Laboratory Technicians, X-ray staff, Doctors, Technicians, Pharmaceutical Technologies, etc.)......................................................
........................................................................................................................
(b) Attach copies of documentary evidence in each case. (Use extra space if necessary).
(i) ....................................................................................................................
........................................................................................................................
(ii) ................................................................................................................
........................................................................................................................
(iii) .............................................................................................................
...................................................................................................................
(iv) .............................................................................................................
........................................................................................................................
(v)...................................................................................................................
........................................................................................................................
(vi)..................................................................................................................
PART V
(To be completed by the Medical Officer of Health in triplicate)
INSPECTION REPORT FOR PRIVATE MEDICAL INSTITUTION FOR REGISTRATION PURPOSES
1. Name of institution .................................................................................
........................................................................................................................
2. Physical Location—
| (a) |
Plot No./L.R. No. ..........................................................................
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| (b) |
Market/Centre/Town* .................................................
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| (c) |
Street/Road* ...............................................................
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| (d) |
Division .........................................................................
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| (e) |
District ..........................................................................
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| (f) |
Province ........................................................................
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3. Premises General Information—
| (a) |
Plot area (in hectares) .........................................................................
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| (b) |
Water supply.........................................................................
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| (c) |
Refuse Disposal—.........................................................................
| (i) |
Incinerator available/Not available*
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| (i) |
Other modes of refuse disposal
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(Specify)
........................................................................................................................
........................................................................................................................
*Delete where inapplicable
(d) Environmental suitability ..........................................................................
recommended/not recommended. *State reasons for not recommending.
........................................................................................................................
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........................................................................................................................
........................................................................................................................
........................................................................................................................
4. Plan of the Institution—
(a) Approved/Not approved* by the local District Development Committee (attach copy of the plan) and documentary evidence (copies) of approval of the institution by the D.D.C.
5. Out-patient Services—
(See attached minimum requirements for General Practice.)
(a) Waiting Bay/Reception Area/Room*—
(i) Seating capacity ..........................................................................
(ii) Area (in square metres) .............................................................
(iii) Construction ................................................ covered/not covered*.
(b) Examination Rooms—
(i) Number of rooms .................................................................................
(ii) State if equipment inspected meets the minimum requirements.
(Attach separate signed list of equipment inspected if necessary).
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
(c) Treatment rooms—
(i) Number of rooms.
(ii) State if equipment meets the minimum requirements.
(Attach separate signed list of equipment inspected).
6. In-patient Services—
(a) Female Ward—
(i) Size of ward (in square metres) ..............................................
(ii) Number of beds .......................................................................
(iii) Number of toilets ....................................................................
(iv) Number of bathrooms ...........................................................
(v) Number of sluice rooms ........................................................
(b) Male Ward—
(i) Size of ward (in square metres) .......................................
(ii) Number of beds ...............................................................
(iii) Number of toilets ..............................................................
(iv) Number of bathrooms ...........................................................
(v) Number of sluice rooms ........................................................
(c) Maternity Ward—
(i) Size of ward (in square metres) ......................................................
(ii) Number of beds ...............................................................
(iii) Number of toilets ..............................................................
*Delete where inapplicable.
(iv) Number of bathrooms ...........................................................
(v) Number of sluice rooms ........................................................
(d) Paediatric Ward—
(i) Size of ward (in square metres) ......................................................
(ii) Number of beds ...............................................................
(iii) Number of bathrooms ...........................................................
(iv) Number of sluice rooms ........................................................
7. Clinic Support Services—
(a) Pharmacy—
(i) Area of waiting room (in square metres) ............................................
(ii) Number of dispensing windows .....................................................
(iii) Number of anti-biotic (safe cupboards) .........................................
(iv) Number of drug stores ................................................................
(b) Laboratory—
(See attached minimum requirements).
(i) Reception area (in square metres) ........................................
(ii) Seating capacity .....................................................................
(iii) Size of work-room (in square metres) .....................................
(iv) Equipment (Attach a separate signed list of equipment and reagents/chemicals inspected).
(c) X-Ray Unit—
(See attached minimum requirements)
(i) Size of reception area (in square metres) ................................
(ii) Seating capacity .........................................................................
(iii) Number of screening rooms .......................................................
(iv) Standard of radiation protection ...................................................Adequate/Not Adequate*.
(v) Equipment (Attach separate signed list of equipment inspected).
(d) Operating Theatre—
(i) Minor theatre equipment (Attach a separate signed list of equipment inspected).
(ii) Major theatre (indicate by a tick or cross in the box next to the item to show whether available or not available).
Induction room □
Operating room □
Recovery room □
Lighting ...................................... Adequate/Not Adequate*.
Equipment ........................... (attach separate signed list of equipment inspected).
8. Other supporting Services—
(a) Kitchen—
(i) Cooking facility (specify) ..............................................................
(ii) Non-perishable store ..................................... Available/Not Available*.
(iii) Perishable store ............................................ Available/Not Available*.
(b) Laundry type (specify) ............................................................
*Delete where inapplicable
(c) Mortuary—
(i) Available/Not Available*.
(ii) Refrigerated/Not refrigerated*.
(iii) Appropriately located/Not appropriately located*.
If not appropriately located state why ..............................................
...................................................................................................
(iv) Body capacity ...............................................................
(v) Adequate Privacy/Not Adequate Privacy* ................................
(vi) Number of ambulances ........................................................
(vii) Other facility (specify and use extra space if necessary) ........................
(To be completed by the Medical Officer of Health in triplicate)
1. Give full names and designation of members of the D.H.M.T who participated in the inspection of the institution
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Name
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Designation
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(i) ....................................(ii) ............................................(iii) ...........................................(iv) ...........................................(v) ...........................................(vi) .........................................(vii) ........................................(viii) .......................................(ix) .........................................(x) ..........................................
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2. Certificate by M.O.H.
I, Dr. ........................................................................................................................
(State full names in Block Letters)
being the Medical Officer of Health in-charge .......................... District, do hereby certify that the inspection of ................................................ was conducted by the District Health Management Team of ................................ on the ........................................ day of ....................., 20 ............ under my personal supervision.
I further certify that the inspection was witnessed by Dr./Mr./Mrs/Miss ................................
..............................................................................................................................
being the Owner/Director/Applicant* and that ........................................... the said institution does/does not* meet the minimum requirements for Registration/Licensing purposes
Dated this ....................................... day of ........................., 20 ................
Signature ............................................................................................
(Medical Officer of Health)
*Delete where inapplicable
Name of Station .............................................................................
address ..........................................................................................
.........................................................................................................
Telephone Number ........................................................................
___________________________________________________________________
PART VII
*Delete where applicable.
(To be completed by the Applicant/Director/Owner of the institution in triplicate)
I, Dr./Mr./Mrs./Miss* ........................................................................................
(Full Names in Block Letters)
herby certify that all information given by me in this application form is true and correct and that I personally witnessed the inspection which was conducted by the Medical Officer of Health on the .................... day of ......................, 20 .................
Signature ............................................
Names in Full .....................................
Applicant to Note—
This application form must be returned to the Medical Practitioners and Dentists Board within a period not exceeding three months from the date of issue.
Applications which are not returned within the stipulated period shall be time barred.
PART VIII
(For the purposes of vetting application and enforcement of Laws, Regulations and Decisions of the I.R.C. and the Board)
(a) Name of institution acceptable to the I.R.C. ............................................
(b) Type of institution .....................................................................................
(c) Give Names, Types, Locations and Registration Numbers of other institutions operated by the Applicant/Director or affiliated to the institution named in this application.
(i) ................................................................................................................................................................................................(ii) ............................................................................................................................................................................................(iii) ................................................................................................................................................................................................(iv) .....................................................................................................................................................................................................(v) .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
(Use extra space if necessary)
(d) Give full particulars of criminal court proceedings for violations of any of the following Ministry of Health laws by any of the Institutions named in paragraph (c)—
Caps. 253, 260, 244, 245, 254 and 242 (quote court case references in each case for the past three years proceeding the date of this application.)
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
(Use extra space if necessary).
(e) Give names of institutions, their location and registration numbers from among those named in paragraph (c) which have defaulted in licence fees payment during the past three years. State each year of default and penalty imposed and whether or not penalty has been paid and fees recovered—
................................................................................................................
................................................................................................................
................................................................................................................
(f) Give names of any of the institutions named in paragraph (c) which the Board has authorized closure during the past three years (quote minutes references of the I.R.C. and state the institutions. Registration Numbers and place of location).
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
(Use extra space if necessary).
(g) F.R.L. Serial No. and date of this application ................................................
(h) Licence Fees Category (Quote I.R.C. minutes reference) ...........................
(i) F.R.L. Receipt No. and Date ...................................................................
(j) Date application returned to applicant ......................................................
(k) Date application re-submitted by applicant ................................................
(l) Registration fees Receipt No. and Date ..................................................
CERTIFICATE BY AN OFFICER AUTHORIZED FOR THE PURPOSES OF PART VII OF THIS APPLICATION
(This certificate must be countersigned by the Registrar)
I, certify that the institution for which this application is made and its Owner/Director/Applicant or its Administrator has/has not* been subject of criminal court proceedings in violation of any of the laws named in Part VIII (d) in this application and that all information given under Part VIII of this application is correct and true.
Dated this ........................................................ day of ................................, 20 ....................
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...............................................Authorized Officer
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............................................................Registrar, M.P. and D.B./D.M.S.
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__________________________
* Delete where inapplicable
FOR OFFICIAL USE ONLY
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1. Institution
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Registration
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Committee
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Recommendation
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Dated this ........................................... day of ..................................., 20.........
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....................................................Chairman,Medical Practitioners and Dentists Board
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...............................................Chairman, Committee
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INSTRUCTIONS TO THE REGISTRAR BY THE BOARD
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Dated this ......................... day of .............................., 20 .............
................................................
Chairman,
Medical Practitioners and Dentists Board
FORM X
(Rule 4(3))
[L.N. 26/2000, s.2.]
Serial No. ..............................
MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
CERTIFICATE OF REGISTRATION AS A PRIVATE MEDICAL INSTITUTION
1. Name of Institution ...............................................................................................................................................................................P.O. Box .........................................................................................................................................................................................2. Type ..........................................................................................................................................................................................................................................................................................has been registered as a Private Medical Institution in accordance
with rule 4(3) of the Medical Practitioners and Dentists (Private
Medical Institutions) Rules.
Date ...........................................................................
SEAL OF THE BOARD
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...........................................CHAIRMAN M.P. & D. BOARD
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..........................................REGISTRAR M.P. & BOARD/DMS
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(a) It shall be the duty of the holder of this certificate to inform the Registrar within fourteen (14) days of any change in the registered address in accordance with section 5 of the Medical Practitioners and Dentists (Private Medical Institutions) Rules.
Form XI
(r. 5(1))
[L.N. 26/2000, s. 2.]
Serial No. ..........................
MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
APPLICATION FOR LICENCE OR RENEWAL OF LICENCE TO OPERATE A PRIVATE MEDICAL INSTITUTION
PART A
(to be completed by the applicant in triplicate)
1. Full name and Address of Institution ................................................................................................................................................................................................................................................................
2. Registration Number and Date of Registration ..........................................................................................................................................................................................................................................
3. Previous Number and Date of Registration ......................................................................................................................................
4. Type of Institution .................................................................
....................................................................................................
5. Previous Licensing Category and Number of Annual Fees Assessment Form ............
....................................................................................................
6. Physical Location of Institution ..............................................
....................................................................................................
7. Specify whether this is a New Application or a Renewal ..........................
....................................................................................................
8. N.H.I.F. Category .......................................................................
Signature of Applicant ...................................................................
Date ................................................................................................
Form XII
(r. 5(3))
Serial No. ...............................
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
ANNUAL FEES ASSESSMENT FORM
PART A
(to be completed in triplicate)
1. Name of Institution .................................................................................................................................................................
2. Registration Number and Date .........................................................................................................................................
3. Physical Location ........................................................
4. Name and Address of Applicant for Licence ......................................................................................................................................................................................................................................................................
5. Fees Category for Year ..........................................................
(i) □
(ii) □
(iii) □
(iv) □
(v) □
(tick relevant box)
6. Fees Rates Applicable to Institution .............................................
Licence fees (amount in words) ......................................................
.........................................................................................................
PART B
(to be completed by M.O.H. in triplicate)
CERTIFICATE BY MEDICAL OFFICER OF HEALTH
I, Dr. (Full Names in Block Letters) .................................................
Being the Medical Officer of Health In-Charge ....................................
.........................................................................................................
District of ...................................................................................
Province do hereby certify that the institution named in this application form was last inspected on ....................................................... day of ..............................., 20 ............. and in myopinion the current condition of its premises requires/does not* require fresh inspection.
Dated this .................................. day of ..............................., 20 ............
OFFICIAL SEAL
...............................................
Medical Officer Of Health
STATION ..........................
ADDRESS .......................
TELEPHONE ...................
(a) Plot No. ..................................................................
(b) Town/Market* ........................................................
(c) Street/Road* .........................................................
(d) Location ................................................................
(e) Division .................................................................
(f) District ...................................................................
(g) Province .................................................................
7. Date of last inspection of the Institution by the Ministry of Health ..........................
...................................................................................................................................
*Delete where inapplicable.
PART C
(to be completed by the applicant in triplicate)
CERTIFICATE BY THE APPLICANT
I, Dr./Mr./Mrs./Miss (Full Names in Block Letters) ......................................
...................................................................................................................................
of P. O. Box ..........................................................................................
being the Administrator/Owner/Director* (Specify other) .............................
...................................................................................................................................
of (give full names of the institution) .................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
do hereby certify that the information given by me in this application is true and correct.
Dated this .......................................... day of ....................................., 20 ...............
..............................................
Applicant
PART D
(For Official use only)
(a) Acceptable name of institution and type .............................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
(b) FRL Serial Number and Date ............................................................................
...................................................................................................................................
(c) Registration Certificate Number and Date .....................................................
...................................................................................................................................
(d) Licence Fees Assessment Number and Date ......................................
...................................................................................................................................
(e) Category of Licensing ...................................................
...................................................................................................................................
(f) Registration Fees Receipt Number and Date ........................................
...................................................................................................................................
(g) Date application sent to IRC/Board ...........................................................
...................................................................................................................................
(h) Remarks .......................................................................................
...................................................................................................................................
I certify that I have personally checked the information above and found it correct and that all procedures and documentation pertaining to this application have been compiled with.
Dated this ........................................ day of .............................., 20 .......................
......................................................
Registrar M.P. & D.B./Director of Medical Services
Form XIII
(r. 5(4))
[L.N. 26/2000, Section 2.]
Serial No. ..............................
MEDICAL PRACTITIONERS AND DENTISTS ACT
(CAP. 253)
LICENCE TO OPERATE A PRIVATE MEDICAL INSTITUTION
LICENCE No. .......................
1. Name of Institution .................................................................................
(Full Names in Block Letters)
of P. O. Box ..............................................................................................(full address) is hereby licensed to operate a Private Medical Institution
in accordance with the provisions of rule 5(4) of the Medical Practitioners
and Dentists (Private Medical Institutions) Rules.
2. This licence entitles the Private Medical Institution to operate as ..............................
........................................................................................................................................
3. Authorized Premises for the Institution ................................................................
........................................................................................................................................
4. Maximum Number of Patients ..............................................................................
5. This Licence shall expire on the last day of ......................................., 20 ............
6. No change of premises is permitted without the authority of the Board.
Dated this ................................. day of ............................., 20 ............
.........................................
Registrar
MEDICAL PRACTITIONERS AND DENTISTS BOARD/DIRECTOR
OF MEDICAL SERVICES
CONDITIONS OF LICENCE
This licence is issued on condition that minimum requirements set by the Board for operation of the Private Medical Institutions are adhered to at all times.
Form XIV
[L.N. 75/2012, s. 3.]
CHECKLIST FOR SINGULAR/JOINT INSPECTIONS FOR PRIVATE OUT PATIENT MEDICAL INSTITUTIONS BY HEALTH REGULATORY BODIES
IN THE MINISTRIES RESPONSIBLE FOR HEALTH
MEDICAL/DENTAL CLINIC/LABORATORY/PHARMACY/RADIOLOGY/X-RAY UNIT/MORTUARY
|
Date:
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Basic Information
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.
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1. Name facility
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2.
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Address
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.
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(a) Physical
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.
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Building
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.
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County
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.
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Ward/Town/Street
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.
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L.R No.
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.
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Tel No./Mobile
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Email
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.
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(b) Postal
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Code
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3. (a)
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Proprietor
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.
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Name
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.
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Profession
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.
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Pin No:
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.
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(b)
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Registered owner
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.
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(a) Name
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.
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(b) Licence Certificate No.
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Date of issue
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Expiry date
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4.
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Officer in charge
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.
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(a) Qualification
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.
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(b) Registration No.
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Practice licence number
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5. Name of Medical Personnel
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Cadre
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Licence Number
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Date of issue
|
Expiry Date
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6.
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Services offered
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.
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.
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.
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.
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7.
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Security of premises (external security & security features)(permanent perimeter fence/fire assembly points/security guards)
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|
|
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8.
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General cleanliness of premises
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|
.
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Total
|
10
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|
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|
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A. Medical/Dental Clinic
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Max score
|
Awarded
|
Comments
|
|
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1. Consultation-Examination rooms
|
|
.
|
|
|
1.
|
Examination Equipment
|
4
|
|
|
|
2.
|
Resuscitation tray
|
3
|
|
.
|
|
3.
|
Infection prevention & control
|
3
|
.
|
|
|
4.
|
Policy, guidelines & SOPs
|
3
|
|
.
|
|
5.
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Medical records
|
4
|
.
|
|
|
6.
|
Data Security
|
4
|
|
.
|
|
7.
|
HMIS/EMR
|
4
|
.
|
|
|
8.
|
Reports
|
3
|
|
.
|
|
9.
|
Ventilation
|
2
|
.
|
|
|
10.
|
Licences
|
10
|
|
|
|
|
Total
|
40
|
.
|
|
|
|
B. Pharmacy/Chemist
|
Max score
|
Awarded
|
|
|
1.
|
Security for medications (e.g. Secure cupboards for restricted drugs, only accessible by authorized persons & disposal of expired drugs)
|
10
|
.
|
|
|
2.
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Storage of drugs/display/labelling/packaging conditions
|
7
|
|
.
|
|
3.
|
Record-keeping and documentation (Prescription written & received and filed/medication errors documented and reported)
|
10
|
.
|
|
|
4.
|
Reference materials, Policy and SOPs as per national guidelines
|
3
|
|
.
|
|
5.
|
Licences
|
10
|
.
|
|
|
|
Total
|
40
|
|
.
|
|
|
C. Laboratory
|
Max score
|
Awarded
|
Comments
|
|
1.
|
Class of the licence (A-E)
|
4
|
.
|
|
|
2.
|
Policies, guidelines and SOPs (including reporting procedures, handling/labelling/storage/disposal of specimens and safety program)
|
3
|
|
.
|
|
3.
|
Equipment management program (manuals, inventory, service contract, calibration)
|
6
|
.
|
|
|
4.
|
Record-keeping & Quality control of tests (EQA, IQA, control of analytical errors)
|
10
|
|
|
|
5.
|
Infection prevention and control
|
2
|
.
|
|
|
6.
|
Registration, storage of equipment and reagents (is there a temperature recording system)
|
5
|
|
.
|
|
7.
|
Licences
|
10
|
.
|
|
|
|
Total
|
40
|
|
.
|
|
|
D. Radiology/Imaging services
|
Max score
|
Awarded
|
Comments
|
|
1.
|
Current annual premises & device licence
|
4
|
.
|
|
|
2.
|
Policies and SOPS (Cod of practice including reporting, testing, calibrating, monitoring and control)
|
3
|
|
.
|
|
3.
|
Quality assurance program (safety of the patient, worker, environment, security, film storage, quality and documentation)
|
10
|
.
|
|
|
4.
|
Personal radiation monitoring (Badges, dose reports)
|
10
|
|
.
|
|
5.
|
Radioactive waste management programs
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3
|
.
|
|
|
|
Total
|
30
|
|
.
|
|
|
E. Nutrition
|
|
.
|
|
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1.
|
Basic Nutrition equipment and materials (weighing Stadiometer, MUAC, BP machine, Blood sugar machine, reference charts)
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10
|
|
|
|
2.
|
SOPs (Nutrition assessment, Nutrition supplements)
|
3
|
.
|
|
|
3.
|
Nutrition care process, nutrition assessment, Diagnosis, intervention, M&E)
|
7
|
|
.
|
|
4.
|
Record keeping and documentation
|
10
|
.
|
|
|
5.
|
Licences
|
10
|
|
.
|
|
|
Total
|
40
|
.
|
|
|
10.
|
Findings and Recommendations
|
|
|
|
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11.
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REGISTERED OWNER/OFFICER IN-CHARGE
|
|
Name ...................................... Designation ......................... Email ...........................Tel No. .............................................. Date ................................ Sign ..............................
|
|
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INSPECTION TEAM
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|
|
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Name
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Board/Council/MOH
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Designation
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Sign
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Date
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1.
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.
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2.
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.
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|
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3.
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.
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4.
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|
.
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|
|
|
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5.
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.
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|
|
|
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6.
|
|
|
|
|
.
|
Form XV
[L.N. 75/2012, s. 3]
|
CHECKLIST FOR SINGULAR/JOINT INSPECTIONS FOR PRIVATE INPATIENT MEDICAL INSTITUTIONS BY HEALTH REGULATORY BODIES IN
THE MINISTRIES RESPONSIBLE FOR HEALTH
|
|
.
|
|
Basic Information
|
|
|
|
1. Name facility
|
|
N/A
|
|
2. Category of Facility
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Level
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N/A (to be graded at the time of registration
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|
3. Proprietor/owner
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|
N/A
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|
|
|
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(a) Organization
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Private ( ), Faith based ( ), GOK ( ), Community based ( )
|
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N/A
|
|
(b) Proprietor’s name
|
|
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N/A
|
|
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(III) Expiry date of the current licence
|
|
5
|
|
|
|
Not matching
|
1
|
|
|
|
matching
|
5
|
|
4.
|
Name of Officer in charge
|
Current practicing licence No.
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|
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N/A
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|
|
.
|
|
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N/A
|
|
|
|
.
|
|
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N/A
|
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5.
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Address
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|
|
|
.
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Physical
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County
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|
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N/A
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|
.
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Plot No., Building
|
|
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Street, Town
|
|
.
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Tel. No
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|
.
|
|
|
|
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Email
|
.
|
|
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|
|
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Postal
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Box No.
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|
Code:
|
N/A
|
|
6.
|
Medical Personnel
|
|
.
|
|
N/A (to be graded at the time of registration.
|
|
|
Name of Medical Personnel
|
Cadre
|
Licence Number
|
Date of issue
|
Expiry date
|
|
|
|
.
|
|
|
.
|
|
|
.
|
|
|
.
|
|
|
|
Total number of staff
|
|
.
|
|
.
|
|
7.
|
Services offered
|
.
|
|
.
|
|
|
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Outpatient Services Y/N
|
MCH( ) & HCT( )
|
|
|
N/A
|
|
|
Inpatient Services
|
YES/NO (tick circle)
|
Number of beds
|
Number of cots
|
N/A
|
|
8.
|
Health Facility Infrastructure
|
.
|
|
.
|
Score
|
|
|
A. Building
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Yes
|
No
|
N/A
|
|
|
1.
|
Building suitable for scope of work
|
|
.
|
|
.
|
|
2.
|
Signage for directions is in place and clear
|
.
|
|
.
|
|
|
|
B. Environmental-Infection Prevention
|
Yes
|
No
|
N/A
|
Comments
|
|
1.
|
Adequate waste management & disposal (according to guidelines)
|
|
.
|
|
.
|
|
2.
|
Personal protective equipment available (Gloves, gowns or dust coats, and safety boots for infection prevention)
|
.
|
|
.
|
|
|
|
C. Utilities
|
Yes
|
No
|
N/A
|
Comments
|
|
1.
|
Safe, clean running water available — (Tap or container). Sufficient water storage available
|
.
|
|
.
|
|
|
2.
|
Stable electrical power supply
|
|
.
|
|
|
|
.
|
Key: Ranking scoresLevel 0: the desired activity is absent, or there is mostly ad hoc activity related to risk reductionLevel 1: the structure of more uniform risk-reduction activity begins to emergeLevel 2: the processes are in place for consistent and effective risk-reduction activitiesLevel 3: there are data to confirm successful risk-reduction strategies and continue improvement
|
|
9.
|
Management & Recording
|
|
|
|
Scoring key
|
|
|
|
|
|
|
|
A. General management
|
1
|
2
|
3
|
4
|
5
|
Comments
|
|
1.
|
Strategic plan with Vision/Mission/Values/Objectives identified
|
|
|
.
|
|
|
1. Not available2. Available but not in use3. In use, not known to all4. In use, not displayed5. Displayed, known and fully used
|
|
2.
|
Organization chart available
|
|
.
|
|
|
|
1. Approved by management2. Approved by board3. Approved by an accredited body
|
|
|
|
Scoring key
|
|
|
.
|
|
|
|
|
|
1
|
2
|
3
|
4
|
5
|
Comments
|
|
3.
|
Service charter displayed
|
|
|
.
|
|
|
1. Approved by management2. Approved by board3. Approved by an accredited body
|
|
|
|
Scoring key
|
|
.
|
|
|
|
|
|
|
1
|
2
|
3
|
4
|
5
|
Comments
|
|
3.
|
Service charter displayed
|
|
|
|
.
|
|
1. Not displayed2. Displayed3. Regular performance review
|
|
4.
|
List of all staff working, including position and qualifications
|
|
.
|
|
|
|
1. No list2. List available3. List with qualifications and Job description4. List with qualifications and Job description5. Staff development plan available
|
|
|
B. Quality Management
|
|
|
|
.
|
|
Comments
|
|
1.
|
Certifications/accreditations
|
|
|
|
|
.
|
No scoring (Yes or No)
|
|
2.
|
Performance indications monitored
|
|
.
|
|
|
|
1. Performance indicators (PI) not collected2. Pls collected routinely3. Pls analyzed4. There’s feedback5. External publications
|
|
3.
|
Patients charter
|
|
|
|
.
|
|
1. Not available2. Available3. Displayed
|
|
4.
|
Feedback mechanism in place
|
|
.
|
|
|
|
1. No policy2. Policy available3. Collection Mechanism available4. Regular analysis of complaints & compliments5. Evidence of action
|
|
|
C. Medical Records & Information Systems
|
|
|
|
|
.
|
Comments
|
|
1.
|
|
|
|
|
|
|
|
|
|
|
Scoring key
|
|
|
|
|
|
|
|
|
1
|
2
|
3
|
4
|
5
|
Comments
|
|
2.
|
Medical records for each patient (files — manual/electronic)
|
|
.
|
|
|
|
1. No medical records2. Separate medical record for each patient3. All patients are triaged4. Comprehensive medical notes5. Notes are legible and signed
|
|
3.
|
Approved register is kept of all patients (An outpatient and inpatient register)
|
|
|
|
.
|
|
1. No registers2. Old registers3. Current registers available4. Registers correctly used5. Notes are legible and signed
|
|
4.
|
Records are kept in a secure place
|
.
|
|
|
|
|
1. No restricted access to files2. There’s restricted access to files3. Files kept in lockable cabinets and only authorized persons can access
|
|
5.
|
Contributes to external databases and reports periodically (Linkage to national HMIS)
|
|
|
|
.
|
|
1. No routine reports2. Routine reports available but not reported3. Routine reports submitted irregularly4. Routine reports submitted regularly
|
|
|
D. Equipment Management
|
|
.
|
|
|
|
Comments
|
|
1.
|
Preventive maintenance plan for equipment
|
|
|
|
.
|
|
1. No preventive plan2. Service contract available3. Equipment checked on schedule and results documented4. Due date for next maintenance documented
|
|
|
|
1
|
2
|
3
|
4
|
5
|
Comments
|
|
2.
|
Calibration
|
|
.
|
|
|
|
1. Machines not calibration2. No contract for calibration3. Calibration not regular but contract available4. Calibration regular with results available
|
|
10.
|
Patient Services
|
|
|
|
.
|
|
|
|
|
|
|
.
|
|
|
Scoring system
|
Comments
|
|
|
A. Consultation
|
|
|
|
.
|
|
|
|
1.
|
Consultation — Examination rooms
|
1. Examination coach2. The above with screen3. The above with steps4. The above with mackintosh5. All the above with bed sheet
|
|
|
2.
|
Sink/wash basin
|
1. Sink available2. The above with Sink without running water3. The above with steps4. The above with Sink with running water from the tap5. All the above with Sink with running water and drier
|
|
|
3.
|
Examination Equipment
|
● thermometer● stethoscope● BP machine● weighing machine● Diagnostic kit
|
|
|
|
|
Scoring system
|
Comments
|
|
|
B. Emergency/Resuscitation room
|
|
|
|
Triage
|
|
1. Triage area2. Nurse not trained in triage3. Nurse trained in triage4. SOPs of triage available5. Proper coding of client
|
|
|
2.
|
Emergency tray
|
● Incomplete emergency tray● Presence of emergency tray with all requirements● The racks clearly labelled● All the above at designated sites● All the above and up to date list of all requirements
|
|
|
3.
|
Equipment
|
● Ambu bag/masks● Suction machine● Oxygen cylinder and flowmeter● Endotracheal tubes● All the above with an ideal adjustable bed
|
|
|
|
C. Sterilization Process
|
|
.
|
|
1.
|
Central Supply Unit
|
1. Separation areas for cleaning 2. Decontamination 3. Sterilization Process — SOPs available 4. Storage of sterile supplies 5. All the above labelled and stored in designated area
|
|
|
|
|
Scoring system
|
Comments
|
|
2.
|
Autoclave Machine
|
● Autoclave manual available ● Autoclave electric available ● SOPs available ● Maintenance plan ● Digitalized autoclave
|
|
|
|
D. Labour Ward
|
|
|
|
1.
|
Procedures for obstetric emergencies
|
1. Procedure for obstructed labour and foetal distress2. Procedure for Eclampsia3. Procedure for APH/PPH/HELLP4. Availability of resuscitaire5. Resuscitaire with oxygen, the suction machine, ambu bags
|
|
|
2.
|
Equipments
|
● Delivery bad available ● Sterile delivery set ● Vacuum extractor ● Suction machine ● Maintenance plan
|
|
|
3.
|
Monitoring of Labour
|
● Partograph chart available● Contraction properly charted● Cervical dilatation Colour coding ● TPR/BP
|
|
|
4.
|
Access to theatre
|
1. Ambulance available 2. General theatre available (not close to L/W) 3. General theatre available (close to L/W)
|
|
|
|
|
Scoring system
|
Comments
|
|
|
|
4. More than one theatre 5. L/W fully equipped theatre
|
|
|
5.
|
Incubator
|
1. Presence of incubator 2. Functional incubator 3. Proper temperature regulation 4. Oxygen connection 5. Maintenance plan
|
|
|
6.
|
Hand washing facility
|
1. Sink 2. Sink without running water 3. Sink with running water from the tap 4. Sink with all the above with soap 5. Sink with running water and drier
|
|
|
7.
|
Sluice room
|
1. Presence of sluice room 2. Sluicing sink 3. Availability of running water 4. Decontamination bucket available 5. SOPs
|
|
|
8.
|
Waste management
|
1. Available Waste bins 2. Coded bins with improper lining 3. Bins with proper coded lining 4. Good segregation practice 5. All the above with SOPs
|
|
|
|
|
Scoring system
|
Comments
|
|
9.
|
State of floor
|
1. Cement floor 2. Cement floor with drainage 3. Ceramic tile floor with drainage 4. Tarazo with good drainage 5. A cleaning chart
|
|
|
10.
|
Nursing Personnel
|
1. Nurses available 2. Midwives available 3. Midwives available but not the right ration 1:3 4. Midwives ratio of 1:2 5. Midwives available ratio 1:1
|
|
|
11.
|
Oxygen source
|
1. Oxygen cylinders available 2. External oxygen piped to L/W 3. Oxygen plant SOPS 4. Maintenance plan
|
|
|
|
E. Clinical Wards
|
|
|
|
1.
|
Oversight of patients
|
1. Admission procedures 2. Categorization 3. Patients uniform 4. Clinical ward round 5. Handing over/discharge reports
|
|
|
2.
|
Patient records
|
1. Availability 2. Non-Coded filing system 3. Coded filing system 4. Designated and secure storage area E-filing
|
|
|
|
|
Scoring system
|
Comments
|
|
3.
|
Monitoring equipment
|
1. Thermometer 2. Stethoscope 3. BP machine 4. Weighing machine 5. Diagnostic kit
|
|
|
4.
|
Resuscitation tray
|
1. Presence of an emergency tray 2. Presence of emergency tray with the necessary contents 3. The racks clearly labelled 4. All the above at designated sites 5. All the above plus list of updating the contents
|
|
|
|
F. Pharmacy
|
|
|
|
|
|
|
|
|
|
|
SCORE
|
COMMENTS
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
General conditions of premises
|
|
.
|
|
|
|
|
|
|
|
Adequate general condition of premises (Hygiene, sanitation, ventilation, state of repair, running water, light, adequate space, display of drugs)
|
|
|
.
|
|
|
|
|
|
2.
|
Medications
|
|
|
|
.
|
|
|
|
|
|
Conditions of medications adequate (e.g. security, display, labelling, expiry dates)
|
|
|
|
|
|
.
|
|
|
3.
|
Record Keeping/Documentation
|
|
|
.
|
|
|
|
|
|
|
Prescriptions received and recorded
|
|
|
|
|
.
|
|
|
|
|
G. Medical/Dental Laboratory
|
|
|
|
|
|
|
.
|
|
1.
|
Licensing
|
|
|
|
|
|
.
|
|
|
|
Licensed for services per class (C,D,E)
|
|
|
|
|
.
|
|
|
|
2.
|
SOPs
|
|
|
|
.
|
|
|
|
|
|
Standard Operating Procedures & guidelines available (accordingto Class: Including reporting procedures, handling/labelling/storage/disposal of specimens and safety program)
|
|
|
.
|
|
|
|
|
|
|
.
|
|
|
|
SCORE
|
|
|
COMMENTS
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
3.
|
Quality assurance
|
|
.
|
|
|
|
|
|
|
|
Quality control practiced (Equipment/reagent registered, validated, calibrated and quality control of tests, well maintained equipment, storage)
|
|
|
.
|
|
|
|
|
|
4.
|
Infection prevention and control
|
|
|
|
.
|
|
|
|
|
|
Infection prevention and control practices observed (waste management and sharps disposal, Personal protective equipment)
|
|
|
|
|
.
|
|
|
|
|
H. Radiology and Imaging Services
|
|
|
Scoring
|
|
|
.
|
Comments
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
Licences
|
|
.
|
|
|
|
|
|
|
|
Premises & devices
|
|
|
.
|
|
|
|
|
|
2.
|
Safety and storage
|
|
|
|
.
|
|
|
|
|
|
Safety of personnel, environment and patient adequate, quality assurance and equipment management (personal safety and control area safety, waste management)
|
|
|
|
|
|
|
|
|
3.
|
Documentation
|
|
|
|
|
.
|
|
|
|
|
Facility Code of Practice present (including reporting, testing, calibrating, monitoring and control, standard operating procedures)
|
|
|
|
|
|
.
|
|
|
|
I. Food Nutrition and Dietetics
|
|
|
Scoring
|
|
|
|
Comments
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
Nutrition assessment and care plan in place for the patients
|
|
.
|
|
|
|
|
|
|
2.
|
Availability of supplementary, therapeutic, & parental feeds
|
|
|
|
.
|
|
|
|
|
3.
|
Procurement, delivery, inspection & menu and service of food according to laid protocols/procedures
|
|
|
|
|
.
|
|
|
|
4.
|
Food & personnel hygiene and waste disposal Registered Nutritionist & Medically examined kitchen staff
|
|
|
|
|
|
.
|
|
|
|
J. Mortuary/funeral parlour
|
|
|
Scoring
|
|
|
|
Comments
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
SOP for receiving, identification, storage and release of bodies including solid disposal
|
|
|
|
|
|
|
|
|
|
|
|
|
Scoring
|
|
|
|
Comments
|
|
|
|
0
|
2
|
3
|
4
|
5
|
.
|
|
|
2.
|
Protective gear & equipment
|
|
|
|
.
|
|
|
|
|
3.
|
Overall environment
|
|
|
|
|
.
|
|
|
|
|
K. Occupational Therapy
|
|
|
|
|
|
.
|
|
|
|
|
|
|
Scoring
|
|
.
|
|
Comments
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
Trained personnel
|
|
.
|
|
|
|
|
|
|
2.
|
Basic Equipment
|
|
|
|
.
|
|
|
|
|
3.
|
Room
|
|
|
|
|
.
|
|
|
|
|
L. Physiotherapy
|
|
|
|
Scoring
|
|
.
|
Comments
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
Trained personnel
|
|
|
.
|
|
|
|
|
|
2.
|
Room
|
|
|
|
.
|
|
|
|
|
3.
|
Specialized equipment/materials
|
|
|
|
|
.
|
|
|
|
4.
|
SOPs
|
|
|
|
|
|
.
|
|
|
5.
|
records
|
|
|
|
|
|
|
.
|
|
|
O. Medical and Dental Services
|
|
.
|
Scoring
|
|
|
|
Comments
|
|
|
|
0
|
1
|
2
|
3
|
4
|
5
|
|
|
1.
|
Trained personnel
|
|
|
|
|
.
|
|
|
|
2.
|
Basic Equipment
|
|
|
|
.
|
|
|
|
|
3.
|
SOPs
|
|
|
.
|
|
|
|
|
|
4.
|
Rooms
|
|
|
|
.
|
|
|
|
|
11. Findings and Recommendations
|
|
12. REGISTERED OWNER/OFFICER IN-CHARGE
|
|
Name ...................................... Designation ............................. EmailTel No. ..................................... Date ............................... Sign ...........................
|
|
|
INSPECTION TEAM
|
|
|
|
|
|
|
Name
|
Board/Council/MOH
|
Designation
|
Sign
|
Date
|
|
1.
|
.
|
|
|
|
|
|
2.
|
|
.
|
|
|
|
|
3.
|
|
|
.
|
|
|
|
4.
|
|
|
|
.
|
|
|
5.
|
|
|
|
|
.
|
|
6.
|
|
|
.
|
|
|
