Msqhsurvey

Terms and Conditions

Application For Chronic Dialysis

Facility Profile

Facility name

Corporate ownership

Phone no

Fax no

Mailing Address

Address

Street

City

State

Postcode

Country

Customer Information (my organisation is listed as below)

Private

Non Government Organization (NGO)

Others (Please specify)

Detail of Facility Requesting MSQH Survey

The Chronic Dialysis Centre openened in the year:

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