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Facility Registration

HOSPITAL / FACILITY REGISTRATION FORM

Kindly fill in your facility details, we shall revert right on time.

* Fields marked with a red asterisk are mandatory

DETAILS

Basic Facility & Details Form Kenya Health Sector

1 Facility Identification

1. Name of Hospital *

2. Type *

3. Level *

Ownership Type *

4. Years in Operation *

Year Established / Registered *

Business Registration / License No. (optional)

5. County of Operation *

6. Sub-County *

7. Location *

Nearest Land Mark *

8. Postal Address *

9. Hospital Contact *

2 Regulatory & Compliance

FID Code *

SHA Contract Status *

3 Leadership & Contacts

10. Director 1 *

11. Director 2

12. Administrator *

Administrator Contact *

13. Website

14. Email Address *

15. Telephone # *

16. Contact Person *

17. Contact Person Phone *

4 Operations & Capacity

18. Approx. Monthly Patients *

19. Expected No. of Users *

Ward / Bed Capacity *

Operating Hours *

Emergency Services Available? *

Nearest Referral Facility (optional)

Services Offered * (select at least 2)

OPD IPD Maternity Dental Eye Laboratory Radiology Pharmacy Physiotherapy Nutrition HIV / TB / ART MCH Theatre Ambulance Morgue Other

20. Supporting Machines (if any)

5 ICT & Infrastructure Readiness

Current System in Use *

Internet Connectivity Type *

Power Backup *

Number of Computers / Workstations *

LAN / WiFi Availability *

6 Human Resources & Staffing

Total Staff Count *

Number of Clinical Staff *

IT Contact Person *

IT Contact Phone *

Existing ICT Department? *

Have you been given a price for the HMIS?

If yes, enter the amount below. If no, just skip this and proceed to authorization.

Yes No

Amount Quoted (KSh) *

Authorization By *

Designation *

Signature / Date *

Declaration *: I confirm that the information provided in this form is accurate, complete, and truthful to the best of my knowledge. I understand that any false or misleading information may lead to disqualification or legal action.

Thank You!

Your HOSI POA Registration has been submitted successfully. Our team will review your application and get back to you within 30 minutes.