The National HIV/AIDS Strategy (NHAS) was released by the Obama administration in 2010 with the goal of reducing HIV incidence, increasing access to care and treatment, and reducing health disparities among populations most affected by HIV. To help achieve these goals, the NHAS calls for a system-wide approach to fighting HIV that engages key stakeholders including people living with HIV, their families and communities, healthcare providers, state and local governments, and private sector partners. One important tool for achieving this goal is the Nhis Registration Form . . .
You will find information about the type of form you wish to complete in the table. It will show you just how long it will need to finish nhis registration form, exactly what fields you need to fill in and several additional specific details.
| Question | Answer |
|---|---|
| Form Name | Nhis Registration Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | how to register for nhis, nhis form, nhis login, nhisonline com ng |
SERIAL NO… |
ACCREDITATION OF HEALTH CARE FACILITY
APPLICATION FORM
1.Name of health care facility
2.Type of Facility. Tick the appropriate box:
a) □ CHPS Compound |
b) □ Maternity Home |
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c) |
□ Health Centre |
d) □ Clinic |
e) |
□ Polyclinic |
f) □ Primary Hospital |
g) |
□ Secondary Hospital |
h) □ Tertiary Hospital |
i) □ Pharmacy |
j) □ Chemical Shop |
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k) |
□ Laboratory |
l) □ Ultrasound Scan Centre |
m)□ Other
3.Facility Ownership. Tick the appropriate box:
a) □ Government |
b) □ Mission |
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c) |
□ |
d) □ Private |
4. Category of Application. Tick the appropriate box: |
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a) □ New Application |
b) □ Renewal |
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c) |
□ Upgrade |
d) □ |
e)□ Other………………………
5.Registration of company with Registrar General’s Department:
Business Registration Number
Date Registered
Date Last Renewal
6. Registration of health facility with appropriate regulatory body/bodies:
Regulatory Body
Registration Number
Date |
Date Last |
Registered |
Renewal |
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7. Address:
Street address/Location
Postal address
Town/City
District
Region
Tel number
Cell phone number
Fax number
Website
8.Chief Executive/ Administrator/ Proprietor:
i.Name
i i.
iii.Contact number (cell phone)
vi. Qualifications
Institution |
Qualification |
Date |
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9.Services offered tick the appropriate box:
i. □ |
ii. □ |
iii. □ Maternity |
iv. □ Surgery |
v. □ Ophthalmology |
vi. □ Dental |
vii. □ Pharmacy |
viii. □ Chemical shop |
ix. □ Laboratory |
x. □ Ultrasound scan |
xi. □ Diagnostic |
xii. □ CT scan |
xiii. □ Pathology (Specialist) |
xiv. □ Orthopaedics (Specialist) |
xv. □ Other |
9b. If xv. above is applicable, please specify:
…………………………………………………………………………………………
……………………………………………………………………………………
………………………………………………………………………………………
10. Details of Bank Account
a. Bankers…………………………………………. b. Branch……………………………..
c. Account Name……………………………………………………………………….
d. Account Number……………………………………………………………………..
11. Key Professional Staff
Type of Professional
Medical Practitioners
Nurses
Midwives
Pharmacists
Number
Dispensing Technicians
Laboratory Technologist
Laboratory Technicians
Medical Assistants
Doctor Anaesthetist
Nurse Anaesthetists
Dentists
Ophthalmologists
Other (Please specify)
12. Attachments
Please attach copies of the following to your completed Application Form:
a.Certificate of Registration of your facility with the Registrar General’s Department
b.Certificate of Registration of your facility with appropriate regulatory body/bodies
c.Proof of retention of your facility with regulatory body/bodies
d.Certificate of qualification of heads of departments/units
e.Proof of retention of heads of departments/units with regulatory body/bodies where applicable
f.PIN of nurses/midwives where applicable
g.List of names of all professional staff, indicating whether they are
h.Receipt of payment of applicable Accreditation Application fee.
13. Format for listing names of professional staff (See g. under 12 above)
Please use the following format to list your professional staff.
Name of Professional Rank / Position
Please tick whether |
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permanent or temporary |
If temporary /locum, |
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permanent place of |
Permanent |
Temporary/locum |
work |
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14. Declaration
I, ……………………………...………………………………………., the Chief Executive/
Administrator/Proprietor of ………………………………………………………………….
hereby declare that the information given above is correct and that I will be responsible for any falsehood provided.
Signature ………………….…………… Date ……………………………
OFFICIAL USE ONLY
Received by…………………………………………………………………..
Receipt No……………………………………………………………………..
Signature of Officer………………………… Date………………….