List of Personnel and Equipment Form
List of Personnel and Equipment Form
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
List of Personnel
Annex A
Name of Health Facility: __________________________________________________________________________________________
Complete Address : ___________________________________________________________________________________________
PRC STATUS
Specialty Board
Highest Educational
Contractual
Permanent
Certificate (for
Designation/ Attainment and
Name physicians), Reg. Validity Signature
Position Post Graduate Others, specify
specify No. Period
Course (if applicable)
(where applicable)
List of Equipment1
Annex B
Name of Health Facility: __________________________________________________________________________________________
Complete Address : ___________________________________________________________________________________________
1 Equipment should be present, functional, and owned by the hospital applying for license to operate.