Name of Health facility * :

Email * :

Physical Address * :

Postal Address :

Business telephone number * :

LGA * : Select LGA AGUATA ANAMBRA EAST ANAMBRA WEST ANAOCHA AWKA NORTH AWKA SOUTH AYAMELUM DUNUKOFIA EKWUSIGO IDEMILI NORTH IDEMILI SOUTH IHIALA NJIKOKA NNEWI NORTH NNEWI SOUTH OGBARU ONITSHA NORTH ONITSHA SOUTH ORUMBA NORTH ORUMBA SOUTH OYI

Ward * : Select Ward

Name Supervising Officer * :

Contact Telephone Number * :

Position * :

Website Url:

Type of Health Facility * : Select Health Facility Public Private Mission

Class of Health Facility: Select Health Facility Class Tertiary Secondary Primary

CAC Registration Number * :

If Public Type * : LGA STATE FG

Hours of Service * :

Category of Health Facility * :

Select Health Facility Category Comprehensive Health Centre Dental Clinic Dental Hospital Diagnostic Centre: Basic/Special Dispensary Eye Clinic or Optical Centre Eye Hospital – (Ophthalmic Centre or Eye Centre) Home Care Services Industrial Clinic Maternity Home Medical Clinic Medical Laboratory Mortuary Services Nursing / Convalescent Home Physiotherapy Clinic Primary Health Centre Radio Diagnostic Centre Radiotherapy Centre Special Diagnostic Centre Specialist Hospital Tertiary Referral Teaching Hospital

Available Facilities * :

Admission Ward(s)                   Common separate for male and female patients
Autopsy Room
Bathroom Facilities
Beds space                  
Consulting Room(s)                  
Cooling (Body) Chambers
Delivery Room
Dispensing Room
Embalming Room
Labour/Delivery Room
Observation room
Phlebotomy room
Procedure room for I&D, suture
Record keeping facilities
Recovery Room for post-surgery patients with appropriate resuscitative gadgets
Refraction/Treatment Room
Registration facilities
Sitting facilities
Theatre                   Small operating theatre for minor day surgeries needing local anesthesia only Operating theatre for major sugeries with General Anaesthesia
Staff Room/Call room/Staff changing rooms
Toilet Facilities: with water closet
Waiting/Reception Room
Ward(s) with locker and over-bed table for each bed
POWER SUPPLY                   EEDC Standby Generators Renewable Energy
Water Source                   Pipe borne Borehole (regularly treated)

Services * :

Ambulatory Care Unit
Antenatal Care
Catering services
Clinical Information Unit
Dental/Oral Health                   Oral Maxillo fcial surgey Periodontics
Dialysis service
Emergency / Trauma Services
HIV/AIDS Services
Immunisation
In-patient Unit
Intensive Care Unit
LABORATORY SERVICES                   Hematology; blood group serology, etc Clinical Chemistry Bacteriology Histopathology Parasitology
Medical Imaging Services
Morgue Services
Pathology Unit
Pharmacy /Dispensing Unit
Physiotherapy
Radiation Oncology Unit
Radiotherapy Services
Rehab- Allied Health Unit
Surgical/Operating Unit
Medical Services                   Assisted Reproductive Therapy Burns Cardiology Cardiothoracic Dermatology Endocrinology ENT Gastroenterology Geriatric Gynaecology Mental Health Neonatology Neurology Neurosurgery Obstetrics Oncology Ophthalmology Orthopaedics Paediatrics Plastics Radiation Oncology Renal – General Respiratory Urology Vascular surgery
Ambulance
Primary Health Care Services                   Maternal and Child Health Adolescent Health Men Health Care of the Elderly Life Saving Services including minor operations
Blood Bank Services

Equipment * :

Adequate Dental instruments
Amalgamator
Angle Poise Lamp
Appropriate medical waste bins and management.
Auto Refractor
Autoclave
Baby Resuscitaire machine
Basic hand washing facilities under running water
Bench Centrifuge
Binocular Microscope
Delivery Bed/couch
Delivery Instruments and Trolley
Dental tips stools for dentist and dental technician.
Dental X-ray unit
Electrophoresis Machine
Examination couch and screen for physical examination
Eye SCAN
Formalin Tank (optional).
Functional Air/Water jets
Functional compressor and Siro box
Functional Operating Light
Functional Rotary Hand pieces and burs – slow faint and medium.
Functional Suction with disposable catheters
Gymnasium with equipment for professional use
Laboratory Autoclave
Laboratory incubator
Laboratory weighing Scale
Micro-Haematocrit Machine
Ophthalmoscope
Oxygen Cylinders (complete with flow metre and other apparatus for administration)
Parking’s Tonometer
Partograph
Patient monitors
Placenta receiver
Proper hand washing facilities with disposable serviettes
Radiograph viewer
Refrigerated Body Units
Slit Lamp, etc
Sonicaid/Fetoscope
Standard Delivery Bed/Couch
Standard Led Light for illumination
Suction Machine/Sterile Mucus Extractors
Suitable equipment for monitoring fetal heart rate and uterine contractions
Treatment couch
Tri-Lens set
Ultrasonic Scaling Device
ultraviolet and infrared lamps
Viable Dental materials
Visual Activity Chart
Visual Field Analyzer
wax-baths
Weighing scales Pediatrics

Administrative Professional * :

Records technician/clerk * :

Jnr Community Health Extension Worker * :

Community Health Extension Worker * :

Community Health Officer * :

Consultant on specialized field of services * :

Dental nurse/dental surgical assistant * :

Dental Surgeon registered to practice in Nigeria * :

Dental technologist * :

Dental Health Technician * :

Dental therapist * :

Environmental Health Officers * :

Financial Professional * :

Medical Laboratory Scientist/Technologist * :

Medical Laboratory Technician/Assistant * :

Medical Practitioners/Doctor * :

Medical records and secretarial Staff * :

Ophthalmic Nurses * :

Optometrist or Optician with a BSc. Degree or Doctor of Optometry * :

Pathology Assistants/Embalmers * :

Pharmacy Technician * :

Physiotherapist * :

Physiotherapy Assistant * :

Radiographer/Sonographer * :

Registered Nurse * :

Registered Pharmacist * :

Staff Nurse * :

Registered Midwife * :

Staff Midwife * :

DECLARATION
I declare that all information provided in this application is complete and accurate and that all necessary documents are enclosed and shall comply with THE STATE MINISTRY OF HEALTH’s policies, rules and regulations;