Name of Hospital :
1. GENERAL INFORMATION
Owner :
Chief of Hospital/Medical Director :
Classification : General [ ]
Special [ ]
Government [ ]
National [ ]
Local [ ]
Others, please
specify
Private [ ]
Single [ ]
Proprietorship
Partnership [ ]
Corporation [ ]
Civic Organization [ ]
Religious [ ]
Foundation [ ]
Others, please
specify
Page 1 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/
Name of Hospital :
2. SERVICE CAPABILITY
2.2. The hospital shall render quality health services appropriate to the level
of care being provided:
and Procedures
Responsibilities
Written Policies
Master Staffing
Organizational
Written Vision
and Mission
Operations/
Duties and
Manual of
Chart
AVAILABILITY
Plan
SERVICE ( if Available)
REMARKS
Administrative Service
General Administrative
Service
− Records
− Bookkeeping
− Clerical Work
− Maintenance
Patient Transport Service
(May be contracted out;
available for 24 hours)
Clinical Service
General Medicine
General Pediatrics
General Obstetrics and Non-
Surgical Gynecology
Minor Surgery
Emergency and Outpatient
Service
Non-surgical Gynecology involves the diagnosis and treatment of gynecologic problems through
non-surgical or medical means.
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Form HOS-LTO-IT/L1-2007
and Procedures
Responsibilities
Written Policies
Master Staffing
Organizational
Written Vision
and Mission
Operations/
Duties and
Manual of
Chart
AVAILABILITY
Plan
SERVICE ( if Available)
REMARKS
Nursing Service
Minimal Care and
Management
Health Education and
Counseling
As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the minimal or
self-care category, the patient is capable of carrying out daily activities as long as the nurse provides
the necessary materials and supplies.
The health facility must be affiliated with a licensed clinical laboratory and radiology facility.
A licensed pharmacy is optional.
2.4. Programs
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Form HOS-LTO-IT/L1-2007
Newborn Screening (as required by R.A. 9288 Newborn
Screening Act of 2004 and Its Implementing Rules and
Regulations) [ ] Yes [ ] No
Rooming-In (as required by R.A. 7600 The Rooming-In and
Breastfeeding Act of 1992) [ ] Yes [ ] No
Page 6 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/
Name of Hospital :
3. PERSONNEL
3.1. The health facility appoints and allocates personnel who are suitably
qualified, skilled and/or experienced to provide the service and meet
patient needs.
COMPLIANCE STATUS
POSITION REQUIREMENT (FT if Full Time) REMARKS
( if Compliant)
(PT if Part Time)
Administrative
Service
Administrator 1
Clerk (Accounting and 1
records)
Utility Worker 1
Driver (May be 1
contracted out)
Clinical Service
Physician 1 at any time plus
one (1) reliever
The physician must not go on continuous duty for more than forty-eight (48) hours.
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Form HOS-LTO-IT/L1-2007
COMPLIANCE STATUS
POSITION REQUIREMENT (FT if Full Time) REMARKS
( if Compliant)
(PT if Part Time)
Nursing Service
Nurse 1:12 beds at any
time
Nursing Attendant/ 1:24 beds at any
Midwife time
For every three (3) Nurses, there must be one (1) reliever.
Nursing Attendant/Midwife is optional if the Authorized Bed Capacity (ABC) is less than twenty-four
(24) beds. If the ABC is 24 beds and above, the ratio will apply.
For every three (3) Nursing Attendants/Midwives, there must be one (1) reliever.
Page 8 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/
Name of Hospital :
4. EQUIPMENT/INSTRUMENT
4.1. All equipment and instruments necessary for the safe and effective
provision of services are available and are properly maintained.
COMPLIANCE CONDITION
ITEM REQUIREMENT ( if Compliant) ( if Serviceable)
REMARKS
Administrative Service
Emergency Light 1
Fire Extinguisher 1
Standby Generator 1
Transport Vehicle 1
(Available for 24 hours)
Typewriter/Computer 1
Clinical Service
Ambu Bag
− Adult 1
− Pediatric 1
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Form HOS-LTO-IT/L1-2007
COMPLIANCE CONDITION
ITEM REQUIREMENT ( if Compliant) ( if Serviceable)
REMARKS
Page 10 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/
Name of Hospital :
5. PHYSICAL PLANT
5.1. All physical facilities and utility systems necessary for the safe and effective
provision of services are available and are properly maintained.
Administrative Service
Waiting Area
Admitting and Records
Area
Administrative and
Business Office
Staff Toilet
Parking Area for
Transport Vehicle
Clinical Service
Emergency and
Outpatient
− Waiting Area
− Toilet (adjacent or
within ER)
− Nurse Station
− Consultation Area
− Examination and
Treatment Area with
Lavatory/Sink
− Equipment and
Supply Storage Area
− Wheeled Stretcher
Area
Delivery Room
− Birthing Area
− Scrub-up Area
Page 11 of 17
Form HOS-LTO-IT/L1-2007
5.2. Environment
5.3. Occupancy
The location of the hospital complies with all local zoning ordinances.
[ ] Yes [ ] No
5.4. Safety
Exits are restricted to the following types: door leading directly outside
the building, interior stair, ramp, and exterior stair.
[ ] Yes [ ] No
A minimum of two (2) exits, remote from each other, are provided for
each floor of the building. [ ] Yes [ ] No
5.5. Security
The hospital ensures the security of person and property within the
facility. [ ] Yes [ ] No
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Form HOS-LTO-IT/L1-2007
5.6. Lighting and Ventilation
Patients who use mobility aids are able to safely maneuver with the
assistance of their aid within their bed area. [ ] Yes [ ] No
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Form HOS-LTO-IT/L1-2007
The hospital has available water supply that is potable and safe for
drinking. [ ] Yes [ ] No
5.13. Sanitation
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Form HOS-LTO-IT/L1-2007
There are screen wires on doors, windows, and other openings.
[ ] Yes [ ] No
5.14. Maintenance
Floors, walls and ceiling are made of sturdy materials that allow
durability, ease of cleaning and fire resistance. [ ] Yes [ ] No
5.16. Signage
5.17. Permits
The hospital maintains current licenses and permits to ensure safe and
effective operations. [ ] Yes [ ] No
Page 15 of 17
Form HOS-LTO-IT/L1-2007
OR
For Existing Hospital (Secured for License Renewal on a Yearly Basis)
AVAILABILITY DATE
TYPE REMARKS
( if Available) ISSUED
Annual Building
Inspection Certificate
Fire Safety Inspection
Certificate
Sanitary Permit
Health Certificate
Water Source Analysis
Report
Page 16 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/
Name of Hospital :
PERSONS INTERVIEWED:
SURVEYED BY:
DATE ___________________________
TIME ___________________________
Page 17 of 17