Republic of the Philippines

Department of Health
REGIONAL OFFICE IV-A
Regulations, Licensing Enforcement Division
QMMC Compound, Project 4 Quezon City

Name of Facility: ____________________________________________________________

REVIEW CHECKLIST FOR HOSPITAL RENEWAL APPLICATION

Please check the availability of the following documents under YES NO

column Yes or No
Properly accomplished Application for LTO
Signed and notarized sworn statement
List of X-ray Machines (Annex G)
Photocopy of OSL Subscription for one year
Photocopy of Film Badge Dose Reports within the validity period of
hospital license
Certificate of Participation from NRL (if applicable)
Hematology (NKTI)
Chemistry (LCP)
Hepatitis B/HIV/AIDS (SACCL)
Microbiology (RITM)
Dialysis Clinic (When provided by the hospital)
Certificate of Compliance
Documented Quality Assurance Program
Blood Station/Blood Collecting Unit/Blood Bank (When provided by the hospital)
Annual Accomplishment Report using NVBSP
Form
Annual Hospital Statistics Report
Accomplished Health Facility Geographic Form
Latest copy of License to operate
Compliance to Deficiencies (last monitoring) if monitored
Remarks/List of Lacking Documents:

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Evaluated by: __________________________________________________________

(Name and Signature)

Date Evaluated: _______________________________________________________

DOH-C4A-RHF-HOSR-Rev.2