| 1. Name of the Healthcare Organization: |
|
_____________________________________________________ |
|
2. Address: |
|
_____________________________________________________ |
|
_____________________________________________________ |
|
3. Ownership:
Is the organisation a public / government establishment or an independent / private sector provider? |
|
_____________________________________________________ |
|
4. Year in which established: |
|
_____________________________________________________ |
|
5. Contact person (s): |
| • Chief Executive Officer: (or equivalent) |
| Mr./Ms./Dr. |
_________________________________________________________ |
| Tel: |
__________________________ |
Mobile |
______________________ |
| Fax: |
__________________________ |
| E-mail |
_________________________________________________________ |
|
|
| • Accreditation Coordinator: |
| Mr./Ms./Dr. |
________________________________________________________ |
| Tel: |
________________________ |
Mobile |
_____________________ |
| Fax: |
__________________________ |
| E-mail: |
________________________________________________________ |
|
|
|
6. Is the Hospital registered with Local Authorities:
(Where applicable as per the State Norms) |
| _____________________________________________________ |
| 7. Number of Inpatient Beds: (number currently in operation)(please exclude emergency, daycare, recovery room beds etc) |
| _____________________________________________________ |
| 8. OPD & IPD data: |
|
IPD DATA (Past Two year)
|
Period |
Number of Paying Patients Admitted |
|
|
|
| |
|
OPD DATA (Past Two year)
|
Period |
Number of Patients |
|
|
|
| |
|
|
|
|
|
