Application Form for Change of Services

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4 Person-in-charge (Name in block letters) (in Chinese) (Position) (Fax) (E-mail) Qualifications Relevant training – name of course, training institution and when Refresher courses attended in recent two years – name of course, training institution and when 5 Medical in-charge (Name in block letters) (in Chinese) (Position) (Telephone) (Fax) (E-mail) Qualifications 6 Nurse in-charge (Name in block letters) (in Chinese) (Position) (Telephone) (Fax) (E-mail) Qualifications 7 Are the nursing staffs specially trained in this unit / specialty? Yes No NA R2012_CS02 2
If yes, how many of them have received training? 8 Unit practice 8.1 Checking of emergency trolley Once every 8.2 Checking of defibrillator Once every 8.3 Checking of drug stock and expiry date Once every 8.4 Checking of dangerous drugs Once every 8.5 Checking of sterilized items Once every 8.6 Checking of single use items Once every 8.7 Checking of unit stock Once every 8.8 Please provide a list of drills (nature, date and number of participants) done in past 12 months Appendix 9 List of critical or major equipment to support the service Type of major Quantity of Quantity of Schedule of Date of last Date of next equipment equipment equipment maintenance as serviced serviced BEFORE AFTER change per the change in in service manufacturer’s service recommendation R2012_CS02 3
Page 1: HOSPITALS, NURSING HOMES AND MATERN
Page 5 and 6: Annex I 《醫院、護養院

Application Form for Change of Services

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