Terms and Conditions
Application For Chronic Dialysis
Facility Profile
Facility name
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Customer Information (my organisation is listed as below)
Private
Non Government Organization (NGO)
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Detail of Facility Requesting MSQH Survey
The Chronic Dialysis Centre openened in the year:
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
and currently has the following number of dialysis stations where applicable (Please specify number in each type). Please note all dialysis stations must be declaed. Should there be any changes prior to the survey, contact the MSQH as soon as possible.
Number of Non Infection Dialysis Station
Number of Hepatitis C Dialysis Station
Number of Hepatitis B Dialysis Station
Number of Hepatitis B and C Dialysis Station
Others infection cases Dialysis Station (MRSA, HIV)
Total Dialysis Station
The chronic dialysis centre has been surveyed previously (if applicable)
First cycle
Number of cycle
Number of staff:
Medical officer
Staff Nurse/Assistant Medical Officer (with post basic haemodialysis)
Staff Nurse/Assistant Medical Officer
Other staff (Please specify)
Please provide details of major changes in dialysis station numbers, roles, extra services etc since last survey (if applicable)
Does chronic dialysis centre have any subsidiary units under its current management structure? If so please detail the name, dialysis station numbers, type of dialysis machine and distance from the main facility.
Please provide the following details separately as applicable:
Reverse osmosis station
Reprocessing reuse dialyser
Adequacy of dialysis treatment
Other relevant information which may help in the allocation of number of survey days and surveyors
On behalf of the above facility
Person in charge
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