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Application for Accreditation Survey

Application for MSQH 3rd Edition Chronic Dialysis Accreditation Survey
  • The undersigned hereby applies for an Accreditation Survey by Malaysian Society for Quality in Health (here in after called MSQH).
  • The undersigned agrees to facilitate the surveyors appointed by the MSQH to survey the premises, facilities, organisation and operations, including documentation.
  • The undersigned hereby acknowledge to have read the Accreditation Survey Application terms and conditions and agrees to all of them.
  • The undersigned certifies that the contents of this application form are true and correct.

All fields marked with (*) are required.
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CREATE LOGIN ID

Create new Login ID to access this system. I already have Login ID.

use email as Login ID. example: [email protected]
FACILITY PROFILE
Contact Person
Customer Informations
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FACILITY DETAILS

Please complete the following details so that the MSQH better assess the composition of the survey team and the length of survey required.

and currently has the following number of dialysis stations where applicable (*please specify number in each type). Please note all dialysis stations must be declared. Should there be any changes prior to the survey, contact the MSQH as soon as possible.

1. Number of Non Infection Dialysis Station
2. Number of Hepatitis C Dialysis Station
3. Number of Hepatitis B Dialysis Station
4. Number of Hepatitis B and C Dialysis Station
5. Others infection cases Dialysis Station (MRSA, HIV)
Total Dialysis Station 0
# Cycle Date of Survey
-
1. Medical Officer
2. Staff Nurse/Assistant Medical Officer (with post basic haemodialysis)
3. Staff Nurse/Assistant Medical Officer
4. Others staff
Please specify:
LIST OF SERVICE STANDARD
# Service Standard
-

Total No. of Services:
0
MISCELLANEOUS

Please provide the following details separately as applicable:


DECLARATION
Person In Charge / Medical Director
Date:
08/05/2024