APPLY FOR ACCREDITATION

- Step 1 of 5

Full name of organization (including the form of ownership) *

Head of organization (CEO) *

Full name

Planned date of accreditation *

Attention* The specified date is not precisely defined. The final date of the external evaluation is determined by the accrediting body.

Information about the organization

Country *

City *

Form of ownership *

Year of foundation *

Licenses and certificates

From the authorized body in the field of healthcare of the country

Certificate of registration

If applicable

Bank (payment) account *

Account No., name and location of the bank

Type of medical activity *

List the types and profiles of services provided

Organizational structure

Including structural divisions located in a separate building, branches, representative offices and facilities. It is necessary to list the divisions, including those located in a separate building, indicating the capacity, location and details

List the divisions, including those located in a separate building, indicating the capacity, location and details *

1) number of hospital beds: ___ beds and/or capacity of outpatient clinic organization/unit (visits per shift) 2) catchment populations (for PHC) ____; 3) the average number of treated patients during 12 months in the hospital, and (or) visits to the polyclinic during 12 months.; 4) the total number of staff units: __, of which employed: __, vacant: __ 5) list the services outsourced/performed by subcontractors:_________________________________________

Responsible person for providing self-assessment data

Full name, position, contact details

Full name *

Current position *

Phone number

Mobile

Email *

Confirm Email

Official email of medical organization *

Confirm Email

Address of the medical organization

Adress of the medical organization *

Postal index *

Official web page

Facebook

Instagram

Attached documents (original with translations in English or Russian)

Organizational structure (original with translations in English or Russian)

Click or drag a file to this area to upload.

In the form of a scheme/diagram

Staffing table (original with translations in English or Russian)

Click or drag files to this area to upload. You can upload up to 15 files.

In PDF form

State licenses and certificates (original with translations in English or Russian)

Click or drag files to this area to upload. You can upload up to 2 files.

PDF

Constitution of a medical organization (original with translations in English or Russian)

Click or drag files to this area to upload. You can upload up to 2 files.

PDF

Presentation (in English or Russian)

Click or drag files to this area to upload. You can upload up to 11 files.

A general presentation about your organization's activities or a final/annual report (in the form of a presentation)

Signature

Phone

Accreditation сenter for quality in healthcare

Information about the organization

Organizational structure

Responsible person for providing self-assessment data

Address of the medical organization

Attached documents (original with translations in English or Russian)