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Application for Accreditation Survey

Application for MSQH 6th Edition Hospital 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.
Upload file : Only *.pdf is allowed. Maximum size for each file is 10MB.

CREATE LOGIN ID

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

*Login ID / Email:

use email as Login ID. example: [email protected]

FACILITY PROFILE

*Facility Name:

*Corporate Ownership:

*Mailing Address:

*Postcode:

*City:

*State:

Phone No.:

Fax No.:

Email:

Website:

Contact Person

Name:

Phone No.:

Email:

Customer Informations

*Organisation is listed as below:

Survey request letter:

Upload file

Organisation Chart:

Upload file

List of Resident Consultant:
Applicable for Private Hospital

Upload file

Facility/Hospital License:
Applicable for Private Hospital

Upload file

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.

*Hospital/facility openened in the year:

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

*Bed Strength

#	Bed Strength / Services	No. of Beds
-
	Please specify:

Hospital/facility has been surveyed previously

#	Cycle	Date of Survey
-

Approval Additional License from KKM:
Applicable for Private Hospital

Upload file

LIST OF SERVICE STANDARD

*I hereby declare and would like the following services to be surveyed for accreditation.

Yes

*Please select service standards below to indicate the department of functions available:

#	Service Standard
-

Total No. of Services:: 0

MISCELLANEOUS

Please provide details of major changes in bed numbers, roles, extra services etc since the last survey:

Does the hospital/facility have any subsdiary units (located away from the hospital site) under its current management structure? If so, please detail the name, bed numbers, type of each unit and distance from the main facility:

(If applicable) Outsourced Services (Indicate On-site or Off-site Status):

(If applicable) Academic Institution:

(If applicable) Community/Outreach Services - Number of units, full description and distance from main facility:

Other relevant information which may help in the allocation of number of survey days and surveyors:

DECLARATION

On behalf of the above facility, I hereby accept the terms and conditions of the above application as stated and declare that the contents are true and correct.
Terms and Conditions

Person In Charge / Medical Director

*Name:

Date:: 08/05/2024

Application for Accreditation Survey

Application for MSQH 6th Edition Hospital Accreditation Survey

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