Mu 67

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

UBND TNH NG THP

S Y T

CNG HO X HI CH NGHA VIT NAM

c lp- T do- Hnh phc

........................., ngy....... thng... .....nm 20....

BIN BN THM NH
C S DCH V VN CHUYN NGI BNH......................................
I. THNG TIN V C S C THM NH
1.Tn c s khm bnh, cha bnh:.
2. a ch:
3. in thoi:. Email (nu c):.
4. Fax:
II. THNH PHN THAM GIA THM NH
A. Thnh phn on thm nh
+ S Y t:
1. .......................................................; Chc v:...........................................
2. .......................................................; Chc v:...........................................
3. .......................................................; Chc v:...........................................
4. .......................................................; Chc v:...........................................
+ Phng Y t:
1 .......................................................; Chc v:............................................
2. .......................................................; Chc v:............................................
B. i din ca c s c thm nh:
1. ..
2.
III. CN C PHP L THM NH
- Cn c Lut Khm bnh, cha bnh ngy 23 thng 11 nm 2009;
- Cn c Ngh nh s 87/2011/N-CP ngy 27 thng 9 nm 2011 quy nh
chi tit thi hnh mt s iu ca Lut khm bnh, cha bnh;
- Cn c Thng t s 41/2011/TT- BYT ngy 14/11/2011 ca B Y t hng
dn cp chng ch hnh ngh i vi ngi hnh ngh v cp giy php hot
ng i vi c s khm bnh, cha bnh.
- Theo n ngh cp giy php hot ng khm bnh, cha bnh ca ng
(B):
IV. NI DUNG THM NH
1. H s php l: (Lit k y cc giy t c lin quan)

Mu 67
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

...

Nhn xt: ..........

2. T chc b my:
C s khm bnh, cha bnh c qui m........................c t chc nh sau:
a. B phn qun l:
- Ban gim c

Ch c s

- Cc phng: ...
b. B phn chuyn mn:
- .......
- ...
Nhn xt: .....

3. T chc, nhn s:
a. C s c tng s nhn vin: ...... ngi; trong nhn vin lm cng vic
chuyn mn: ....... ngi.
TT
1
2
3

Chc danh

Phng tip nhn

Phng k thut

Tng s

Tng s
TT

Chc danh

Hp ng lm vic
thng xuyn (ton thi
gian)

Hp ng lm vic
khng thng xuyn
(mt phn thi gian)

Tng s

1
2
3
Tng s

b. Ngi chu trch nhim chuyn mn k thut phi c chng ch hnh ngh
v thc hin vic khm bnh, cha bnh trong phm vi phn cng
t Khng t
4. C s vt cht:
- Din tch chungm2, (di.m. x rngm.......);
- Kt cu nh ................................................................
- Trn nh chng bi v c chiu cao ti thiu l 3,1 m:
t Khng t

Mu 67
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- a im c nh
t Khng t
- nh sng
t Khng t
- Tch bit vi ni sinh hot gia nh
t Khng t
- C s ng k .phng, trong :
+ Phng .+ Phng ..
- C s c bin hiu ng qui nh (tn c s, a ch, gi lm vic, ngi ph
trch, in thoi..)
t Khng t
- C ni bnh nhn ngi ch
t Khng t
- C ging bnh s cu, cp cu bnh nhn
t Khng t
- C xe chuyn dng cp cu
Trang thit b trn xe
H thng iu ha khng kh 02 dn lanh, trc v sau
Tay li tr lc c th iu chnh nghing theo ngi li
Kha ca trung tm
ng h in t, ng h o vng tua my
Dn m thanh: Radio Casete (02 loa trc, 01 loa sau)
Gh bc simili cao cp
Ca s bn ngi li iu khin t ng ln xung
Vch ngn ring gia cabin v khoang bnh nhn
Knh mu cao cp
ui c kt hp n bo phanh
S ch ngi 05 ch
Bnh PCCC
H thng an tan

t Khng

t Khng

Ti kh cho ngi li xe
H thng phanh: H thng chng b cng phanh ABS, thng a cho c
04 bnh
H thng treo: Trc kiu MacPherson, sau lin kt a im dng l
xo, a tn nhit
Cm bin li (04 mt)
Trang thit b cu thng
H thng n trn trong khoang bnh nhn
Gi treo dch truyn
Bnh cha oxy
T cha dng c y t
n u tin di trn nc xe dng xoay trc v sau (01 chnh, 02 ph)
T hp ci h a ging v Micro, loa pht thanh
H thng qut thng gi cho khoang bnh nhn
cm in 12V

t Khng

Mu 67
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

5. in, nc, v sinh, v sinh mi trng, phng chy cha chy:

- H thng in, h thng nc m bo
t Khng t
- m bo cc iu kin x l cht thi v v sinh mi trng
t Khng t
- H thng PCCC
t Khng t
- Phng v sinh
t Khng t
6. Thuc, trang thit b dng c y t:
- Thuc v Danh mc trang thit b y t (nh km bin bn)
t Khng t
- Trang b thuc, dng c thit b y t theo quy nh ti Quyt nh s
3385/Q-BYT ngy 18/9 /2012:
+ Danh mc vali thuc cp cu trang b trn xe t cu thng cho mt kp
cp cu ngoi vin (nh km bin bn)
Tt: 75%
t: T 50% - <75% Khng t: < 50%
+ Danh mc thuc, vt t y t thit yu trang b trn xe t cu thng cho
mt kp cp cu ngoi vin (nh km bin bn)
Tt: 75%
t: T 50% - <75% Khng t: < 50%
+ Danh mc vali dng c cp cu trang b trn xe t cu thng cho mt
kp cp cu ngoi vin (nh km bin bn)
Tt: 75%
t: T 50% - <75% Khng t: < 50%
+ Danh mc trang thit b thit yu trang b trn xe t cu thng cho mt
kp cp cu ngoi vin (nh km bin bn)
Tt: 75%
t: T 50% - <75% Khng t: < 50%
- S theo di, qun l qun l bnh nhn
t Khng t
- C dng c tit khun dng c y t
t Khng t
7. Phm vi hnh ngh c th:

..
8. Quy trnh k thut
C bng quy trnh k thut y
t Khng t
9. Gi dch v: C nim yt bng gi dch v
t Khng t
V. KT LUN V KIN NGH
1. Kt lun:
..
2. Kin ngh:
..

Mu 67
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

..
..
..
..
..
..
3. kin khng ng vi kt lun v kin ngh ca on thm nh (nu c)

..
..
..
..
..
..
..
..

Bin bn kt thc lc
TRNG ON

gi

pht, cng ngy.

PHNG Y T

I DIN C S C THM NH

TH K