THE REPUBLIC OF SOMALILAND

APPLICATION FOR THE REGISTRATION OF A HEALTH CARE FACILITY

NB: AN INCOMPLETE FORM WILL DELAY REGISTRATION For Office Use
Please PRINT and Return the Original Form to NHPC Office
Only

Received on:
A. Facility Information
1. Facility Name: .........................................................................
2. Address: .................................................................................. Amount SL.SH:
3. Telephone: ...............................................................................
4. Website: ..........................................................................
Receipt No:
5. Established Date: ....................................................................
6. Current Registration Number: .................................................
7. Authorizing Department: ......................................................... Reg. No:
8. Type of Facility: .......................................................................
i. a) Public: b) Private: c) Private For Non-Profit:
Reg. Date:
Others (Specify): ......................................................................
ii. a) Teaching Hospital: b) University Affiliated Hospital:
B. Facility Director’s Information Assessed by:
1. Director Name: ........................................................................
2. Director’s Title: ........................................................................
Date:
3. Field of study/Specialty: ..........................................................
4. Registration No (Only for Medical Personnel): ..........................
5. Telephone: ............................................................................... Signature:
6. Email: .....................................................................................
C. Locality of Health Unit
Verified by:
1. County/Area: ..........................................................................
2. City/Town/Village: ..................................................................
3. District: ................................................................................... Date:
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4. Region: ....................................................................................
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Signature:
 1. Do you own the property? Yes No

a) If yes (Please attach a photocopy of prove of ownership.

b) If no attach tenancy agreement.

c) Others (Specify):………………………………………………………………………..

D. VISION, MISSION, OBJECTIVES AND CORE VALUES

1. State the vision of the health care institution:

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2. State the mission of the health care institution:
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3. State the objectives of the health care institution:
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4. State the core values of the health care institution:
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E. GOVERNANCE AND MANAGEMENT STRUCTURES

1. State the governance structure of the health care institution:

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2. State the management structure of the health care institution:

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F. INSTITUTIONAL RESOURCES

1. List the names, titles and qualifications of the human resources that are available
to manage/operate the health care institution: If more space is needed, use an
additional sheet and attach it to this form:

Name Title Qualifications

1. State the current sources of funding for the health care institution:
….…………………….…………………………………………………………………………….
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2. State expected sources of funding for the health care institution:
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G. INSTITUTIONAL INFRASTRUCTURE AND FACILITIES AVAILABLE

1. State the existing infrastructure (such as number of wards, rooms, offices,

toilets, and patient waiting areas etc).
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 H. Category of Health Facility (Tick ✓ One)
Note: Use the below chart sheet to select the appropriate categories class:
A| B| C| |D (Please Tick the Appropriate Class)

Class A: Class B Class C Class D

(Such as; National and Regional (Such as; Referral and (Such as; Health Centers and (Such as Diagnostic Centers)
Hospitals) District Hospitals) MCHs))

1. Management 1. Management 1. Management 1. Management

2. Human 2. Human 2. Human 2. Human
Resources Resources Resources Resources
3. Medical Records 3. Medical Records 3. Medical Records 3. Medical Records
4. Facility 4. Facility 4. Facility 4. Facility
Maintenance Maintenance Maintenance Maintenance
5. Equipment 5. Equipment 5. Equipment 5. Equipment
Management Maintenance Maintenance Maintenance
6. Fire And Safety 6. Fire And Safety 6. Fire And Safety 6. Fire and Safety
7. Infection 7. Infection 7. Infection 7. Infection
Prevention Plan Prevention Plan Prevention Plan Prevention Plan
8. Supplies 8. Supplies 8. Supplies 8. Supplies
9. Laboratory 9. Laboratory 9. Laboratory 9. Laboratory
10. Sterilization 10. Sterilization 10. Sterilization 10. Sterilization
process process process process
11. Waste 11. Waste 11. Waste 11. Waste
management. management. management. management.
12. Medications 12. Medications 12. Medications
13. Pharmacy 13. Pharmacy 13. Pharmacy
14. Clinical Practice 14. Clinical Practice 14. Clinical Practice
15. Radiology/Imaging 15. Radiology/ .
Services Imaging Services
16. Dentistry 16. Dentistry
17. Rehabilitation 17. Rehabilitation
18. Quality 18. Quality
Assurance Assurance
19. Blood Bank
20. Operating Rooms/
Anesthesia
21. Emergency
Services
22. IT Services

A) Hospital/Referral/Regional Hospital
Number of Beds
4

Tick All Available Departments:

Page

For additional departments fill the spaces provided

Cardiology Gynecology Pediatric Diagnostic
& Obstetrics Imaging
Dental Medical Physiotherapy Urology
Dermatology Neurology Psychiatric Laboratory
ENT Nephrology Pharmacy A & E depart.
Ophthalmology Orthopedic Surgical Others

B. Hospital/Health Center:
Number of Beds:
Tick All Available Departments: For additional departments fill the spaces provided

Cardiology Gynecology Pediatric Diagnostic

& Obstetrics Imaging
Dental Medical Physiotherapy Urology
Dermatology Neurology Psychiatric Laboratory
ENT Nephrology Pharmacy A & E depart.
Ophthalmology Orthopedic Surgical Others

C. Health Centers and MCHs

Number of Beds:
Tick All Available Departments: For additional departments fill the spaces provided

EPI/ Basic < 5yrs & > Outreach

Immunization Laboratory 5yrs OPD Services
Nutrition Antenatal Postnatal care VCT
Program care
Delivery Unit OPD Pharmacy Others

D. Diagnostic Centers

I. PARTICULARS OF OWNERS (if not government owned)

NB: If more space is needed or the organization has shareholders please attach the list
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Name…………………………………………………………Tel…………………………….

Signature……………………………………………………Date…...............................

Name…………………………………………………………Tel………………………………

Signature…………………………………………………...Date……………………………

Name…………………………………………………………Tel………………………………

Signature……………………………… ……………………Date…………………………….

Name…………………………………………………………Tel………………………………

Signature……………………………… ……………………Date……………………………

Name…………………………………………………………Tel………………………………

Signature……………………………… ……………………Date……………………………

Name…………………………………………………………Tel………………………………

Signature……………………………… ……………………Date……………………………

Name…………………………………………………………Tel………………………………

Signature……………………………… ……………………Date……………………………

Facility Director/Manager/CEO:

Name: …………………………………………………………………………
Title: ………………………………………………………………………..
Signature………………… ………………………………….Date…………………………

NB: In support of your application, please attach the following

required documents to this application.
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1. Request for assessment

 2. Complete application form

3. Institution background

4. List of health professionals.

5. A list of equipment and material.

6. Prove of ownership or tenancy agreement.

7. Prove of business or public registration.

8. Constitution/Article of Association.

9. Strategic plan/business plan (with financial and operational manuals/policies).

10. Prove of current Registration from.

11. Final report of NHPC facility assessment (If assessed by NHPC).

12. A copy of Registrations and Licensure of health care workforce employed

by the institution (such as Doctors, Nurses, Midwifes and other Allied health

workers).

13. Any other supporting document requested by NHPC.

F FOR OFFICIAL USE ONLY

Regulatory Officer:

Full name:

Comments:

...………………………………………………………………………………………………………………………………………………………………………………………
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 Date (DD/MM/YYYY): Signature:

Executive Director:

Full Name

Comments

………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………….

Recommended Not Recommended

Date (DD/MM/YYYY): Signature:

NHPC Chair Person:

Full Name:

Comments

…………………………………………………………………………………………………………………………………………………………………………………………

……………………………..………………………………………………………………………………………………………………………………

Approved Not Approved

Date (DD/MM/YYYY): Signature:

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