Name of Medical Institution:
Application Date:
Receiving Organization:
Receiving Date:
Month, 2012
Instructions for Completion
One, all the contents of the application must be factual, the expression should be clear and rigorous, and the handwriting should be The application must be clear and rigorous, and the handwriting must be legible.
Two copies of this application form should be printed on A4 paper and bound on the left side.
Three, the acceptance of the agency please fill out: Guangdong Provincial Health Department
Four, the basic situation of medical institutions, please fill out the project contact: hemodialysis unit in charge of the name
Five, this application should be accompanied by the following information:
Medical institutions license (copy) and seal
A basic situation of the medical institutions
Name
Nature
Nature □ General Hospital □ Specialized Hospital Others:
Hospital Grade Level Others:
Unit Address
Postal Code Contact Phone Number
Medical Institution In Charge Contact Phone Number
Project Contact Phone Number
Email Fax
Total Area Square Meters No of Beds Personnel on staff
Registration of the corresponding diagnostic and therapeutic subjects
Corresponding
Departmental settings
Two, set up hemodialysis room department basic
Basic situation of the Department of Nephrology Department of Nephrology (or nephrology group of the Department of Nephrology) was established on the year of
Number of beds of Nephrology Department of the beds, the actual opening of the beds.
Number of patients discharged in 2010
Number of staff in the department Physicians, nurses, technicians
Basic situation of hemodialysis room Hemodialysis room Establishment time Year Month
Current number of staff in the hemodialysis room Physicians, nurses, technicians.
The building area of the hemodialysis room
The number of hemodialysis machines
The number of water treatment machines
The number of dialyzer reusers
The number of cardiac defibrillators
The number of simple respirators
The number of resuscitation carts
The number of computers with Internet access
Whether to establish Isolated dialysis room or isolated dialysis area Yes, No.
Three, the person in charge of hemodialysis room profile
Surname Gender Date of birth
Education, degree Title Title Title
Specialty Specialty
Practitioner's certificate No.
Contact number
1. When and where to start working in the specialty
2. . Brief description of professional work (including clinical practice, teaching and major scientific research):
Four, hemodialysis room staff basic information
Name Gender Age Education Title/Title Specialty Engaged in this specialty
Time Physician (nurse) practice certificate number Whether in the tertiary hospital hemodialysis room training for more than 3 months
Five, truthfulness statement
I undertake that the information provided is true and valid.
Department head:
Hospital legal representative:
Unit seal
Year Month Day