MINISTRY OF HEALTH
Brunei Darussalam
APPLICATION FORM FOR ACCREDITATION OF HEALTH FACILITY
Name of Health Facility:
Address:
City:
Country:
Contact Numbers: (Tel) (Fax)
E-mail Address (if available):
1) OWNERSHIP (Please tick)
Private Government
Others (Please specify) ____________________________________________
2) MAIN SOURCES OF INCOME
Put (x) where no such activities took place.
Medical fitness testing ______
Walk in acute medical care ______
Outpatient/GP services ______
Speciality services e.g. surgical ______
Dispensing of drugs ______
Immunization ______
N.B. If you are part of a large hospital or organisation, the following questions only
applies to the department/unit involved in providing pre-departure medical fitness
examination.
3) STAFFING
Number and roles of employed staff
Job category Number
Doctors
Nurses
Administrative
Others (please specify)
4) FLOOR PLAN
No of consultation rooms ____________
Approximate size of consultation room ____________
Is your health facility air conditioned? YES / NO
Designated -registration area Present Absent
-patient records room Present Absent
-general administrative area Present Absent
-Medical Certificate printing room Present Absent
5) WORKING ARRANGEMENT
Length health facility in operation _______________years
Operation hours: ______________ hours/day _____________ days/week
Are registration of workers done: Manually Computerised
Any experience in performing pre-departure medical fitness examination? YES / NO
If currently performing pre-departure medical fitness examination:
- Length in operation performing fitness examination _______________years
- For which countries do the workers that you perform the medical fitness
examination goes to?_____________________________________________
- Number of workers examined per month ______________________________
- Cost of examination per worker ______________(Male)__________(Female)
Number of doctors conducting examination (excluding radiologists and pathologists):
Full time___________
Part time ___________ Please state from which department or health facility:
_________________________________________________________________
Assisting doctors: Nurses
Others (please specify) ___________________________
6) FACILITIES (please tick)
Yes No Remarks
In house Haematology lab
In house Biochemistry lab
In house X ray Machine
Others (please state)
If YES, please state under remarks column if any Quality Assurance or Accreditation
Programmes (e.g ISO) present. If NO, please provide the name and address of other
centers the facility refer to.
7) MEDICAL EXAMINATION PROCEDURE
Do you have your own format of medical fitness examination forms? YES / NO
(If the answer to the above question is YES, please supply a copy of the medical fitness
examination form together with this application)
Are information written on the forms:
Manually?
Typed?
Entered into a computer and later printed?
Do you retain workers medical records? YES / NO
8) RESULTS OF INVESTIGATIONS
i) Are laboratory results:
Manually written?
Typed?
Entered into a computer and later printed?
Who verifies the laboratory results? ________________________________________
If results verified by pathologists, how many are employed there? _______________
How many pathologists are working there : Full Time _________ Part time_______
Are the laboratory results: Given to worker / Not given to worker
ii) Are X-ray reports:
Manually written?
Typed?
Entered into a computer and later printed?
Who reports the X-ray?:_________________________________________________
If reported by radiologists, how many are employed there?_____________________
How many radiologists are working there: Full time __________ Part time________
Is the X-ray film: Given to worker / Not given to worker ?
iii) Is pre-test counseling for HIV testing given to each worker? YES / NO
If HIV positive, result given by (please tick):
Yes No If yes, given by:
By phone?
By mail?
In person?
Is post-test counseling for HIV testing given?
Yes If yes, given by whom?____________________________________
No
9) MEDICAL CERTIFICATE
Do you produce your own particular Medical Certificate or use the respective countries
Medical Certificate format?_______________________________________
Is the information on the Medical Certificate written:
Manually?
Typed?
Entered into a computer and later printed?
Is information written in: English
Others (please specify) _______________________
10) DOCTORS INVOLVED IN THE CONDUCTING OF PRE-DEPARTURE
MEDICAL FITNESS
Please supply the list, copies of qualifications and registration with
local/national/international bodies of doctors involved (including radiologists and
pathologists) in the pre-departure medical fitness examination of workers going overseas
using the following format:
Name:____________________________________________________________
Age:_____________________ Sex: _____________________
Relevant qualifications:______________________________________________
Registration with government bodies:____________________________________
Years of registration:________________________________________________
Full time / Part time in the department/unit:_______________________________
Other commitments e.g. work in hospital or other clinic:_____________________
__________________________________________________________________
Signature (2 samples required):
i)_____________________________ ii)_____________________________
All completed forms to be forwarded to:
1) The Director General of Health Services
Department of Health Services
Ministry of Health
Jalan Menteri Besar
Brunei Darussalam BB 3910
