Self-Assessment Form

Certification Standards
Major Requirements: YES NO

1.Training for ABCT Staff from DOH recognized training institution

2.COLD Chain equipment (Refrigerator and Vaccine Carrier)
3.Trained Medical Doctor
Survey Item Criterion Part I PART II
Evidence by progress ABTC Rating Surveyor’s Comments Survey Team Rating
And achievements
GOAL The Animal Bite Treatment Center Provides a safe and effective physical
environment to its staff and patients
1 The ABTC is easily located and patients have convenient and safe access to the center

This standard will be achieved when:

1.1 There is appropriate

signage bearing the name
of the ABTC to assist
patients
accessing the center.
1.2 Physical Access is
Appropriate for the
Needs of the patients
1.3 Entrance/Exits are
Free of obstruction
And of other
Hazardous conditions
1.4 There are resources
To inform patients of
the daily schedule of
ABTC services
TOTAL RATING
Rating Scale:
0 – Non Compliant
1-Incomplete
2-complete

The DOH/CHD Certification Self-Assessment and Survey Tool

COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM

(To be completed by the survey team only. The survey team must make comments on items where the survey team disagress or partially disagrees with
information provided by the Treatment Center.)

Goal: The Animal Bite Treatment Center provides a safe and effective physical environment to its staff and patient.
Standard 1: The Animal Bite and Treatment Center is easily located and patients have convenient and safe access to the center.

Rating Scale:
0 – Non Compliant
1-Incomplete
2-complete
Certification Standard
Survey Item Criterion PART 1 PART II
Evidence v]by ABTC Rating Surveyor’s Comments
Progress and
Achievements
GOAL The Animal Bite Treatment Center Provides a safe and effective physical environment to its staff and patients
2 The ABTC provides facilities for the comfort and privacy of its patients and staff

This standard will be achieved when:

2.1 The ABTC maintains a
Clean and wholesome
Environment within
And immediately
Outside its premises.
2.2 There are resources
And processes to
Ensure the quality of
Patient waiting.
2.3 The lighting in each
Area of the center is
Appropriate for the
Assigned purpose of the
area.
2.4 The Privacy of the
Patient – is respected
TOTAL RATING

The DOH/CHD Certification Self-Assessment and Survey Tool

Rating Scale:
0 – Non Compliant
1-Incomplete
2-complete
COMMENTS.COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM
(To be completed by the survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with
information provided by the Treatment Center.)

Goal: The Animal Bite Treatment Center provides a safe and effective physical environment to its staff and patient
Standard 2: The ABTC center is provides privacy and comfort of its patient and staff.

Self-Assessment Form
Rating Scale:
0 – Non Compliant
1-Incomplete
2- Complete
Certification Standard
Survey Item Criterion PART 1 PART II
Evidence v]by ABTC Rating Surveyor’s Comments Survey Team Rating
Progress and
Achievements
GOAL The Animal Bite Treatment Center Provides a safe and effective physical environment to its staff and patients
3 The ABTC is easily located and patients have convenient and safe access to the center

This standard will be achieved when:

3.1 THE ABTC has adequate

clean water wound
cleaning personal
hygiene and sanitation
purpose.
3.2 THE ABTC maintains
Appropriate levels of
Cleanliness and
antisepsis of all physical
areas Equipment and
instruments.
3.3(waste management General waste sharps,
And segregation) Pathological and
infectious waste,
pharmaceutical and
chemical wastes are
appropriately
segregated, safety
handled and disposed of
according to accepted
safe disposal practices.
TOTAL RATING
THE DOH/CHD Certification Self-Assessment and Survey Tool
Rating Scale:
1 – Non Compliant
2 – Incomplete
3 - Complete

COMMENTS.COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM

(To be completed by the survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with
information provided by the Treatment Center.)

Goal: The Animal Bite Treatment Center provides a safe and effective physical environment to its staff and patient
Standard 2: The ABTC is easily located and patients have convenient and safe access to the center

Self-Assessment Form
Rating Scale:
0 – Non Compliant
1-Incomplete
2- Complete
Certification Standard
Survey Item Criterion PART 1 PART II
Evidence by Progress ABTC Rating Surveyor’s Comments Survey Team Rating
and Achievements

GOAL The Animal Bite Treatment Center Provides a safe and effective physical environment to its staff and patients
4 All patients have continues access to accurate and reliable Animal bite exposure management and treatment.

This standard will be achieved when:

4.1 A physician completes

And document the
Relevant history for Each
patient.
4.2 Animal Bite Treatment
Center implements
policies and procedures
for assuring the quality
Of bite exposures
management and
treatment.
4.3(waste management If ARV/RIG is not
And segregation) available in ABTC,
Policies and procedures
For referring patients to
Accessible ABTC are
Implemented and
mentored for
effectiveness
4.4 Anti-Rabies vaccines
Are securely stored
Under appropriate
Storage conditions
And observe proper
 Cold chain
Management.

4.5 There are

Documented,
Disseminated, and
Implemented
Procedures to
Identify and address
The risk of
Contamination of
Staff and patients
From sources of
infectious diseases
TOTAL RATING

Rating Scale:
0 – Non Compliant
1-Incomplete
2- Complete
THE DOH/CHD Certification Self-Assessment and Survey Tool

COMMENTS.COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM

(To be completed by the survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with
information provided by the Treatment Center.)

Goal: patients receive adequate and effective diagnostic and therapeutic services at every category of their management and treatment.
Standard 4: all patients have continuous access to accurate and reliable Animal bite exposures management and treatment.

Rating Scale:
0 – Non Compliant
1-Incomplete
2- Complete
Self-Assessment Form

Certification Standard
Survey Item Criterion PART 1 PART II
Evidence v]by ABTC Rating Surveyor’s Comments Survey Team Rating
Progress and
Achievements
GOAL The Animal Bite Treatment Center Provides a safe and effective physical environment to its staff and patients
5 A comprehensive management approach is developed and followed for all patients.

This standard will be achieved when:

5.1 All treatment is consistent

with
Rabies prevention
And Control Program
Revised Guidelines.
5.2 Flow charts of patient
Management and
Treatment from entry to
separation are used to
facilitate quality care
and are accessible to
patients and staff.
5.3 An appropriately
Comprehensive
Evaluation of the
Patient’s progress is
made and document at
each visit.
5.4 Education is provided to
All patients to help them
Understand their
condition and to
encourage their
adherence to
management and
treatment regimen and
health promotion/re-
Exposure prevention
activities.

5.5 Policies and procedures

for detecting PEP
defaulters and getting
them back for treatment
are implemented and
monitored for
effectiveness.
TOTAL RATING

Rating Scale:
0 – Non Compliant
1-Incomplete
2- Complete
The DOH/CHD Certification Self-Assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM
(TO be completed by the survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with
information provided by the Animal Bite and Treatment Center.)

Goal: Patients receive adequate and effective diagnostic and therapeutic services at every category of their management and treatment.
Standard: A comprehensive management approach is developed and followed for all patients.

Rating Scale:
0 Non-Compliant
1 – incomplete
2- complete
Self-Assessment Form

Certification Standard
Survey Item Criterion PART 1 PART II
Evidence v]by ABTC Rating Surveyor’s Comments Survey Team Rating
Progress and
Achievements
GOAL The Animal Bite Treatment Center Provides a safe and effective physical environment to its staff and patients
6 The ABTC maintains an updated reports and records of all Animal Bite Patients.

This standard will be achieved when:

6.1 Each patient is uniquely

identified from entry
throughout the course of
management and
treatment.

6.2 The ABTC maintains a

database of patient
record and related
registries and enables
the staff to easily access
these databases.
6.3 The ABTC keep track of
all registered Animal Bite
Cases.
6.4 Maintains updated
quarterly reports of both
Animal and Human Bite
Cases.
6.5 Maintains an updated
inventory of ARVS.
TOTAL RATING
Rating Scale:
0 – Non compliant
1 – Incomplete
2 – complete

The DOH/CHD Certification Self-Assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM
(TO be completed by the survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with
information provided by the Animal Bite and Treatment Center.)

Goal: Patients receive adequate and effective diagnostic and therapeutic services at every category of their management and treatment.
Standard: The ABTC maintains an updated reports and records of all animal bite patients.

Rating Scale:
0 – Non compliant
1 – Incomplete
2 – complete
OVERALL RATING AND SUMMARY PER GOAL

Goal MAXIMUM RATING TOTAL

ABTC RATING ASSESORS
1 8
2 8
3 6
4 8
5 8
6 10
TOTAL 48

___________________________ ______________________
RATER RATER

COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY THE SURVEY TEAM

(To be completed by the survey tam only. The survey team must make comments on items where the survey team disagrees or partially disagrees or partially
disagrees with information provided by the Animal Bite and Treatment Center.)

Rating Scale:

0 – Non compliant

1 – Incomplete

2 - complete