Institutional Membership Form

(NSRCfm1210.3)

Additional Requirements:

Institutional Profile

Business/Mayors Permit

SEC/DTI

Name of Health Facility

Region

Complete Address
Bldg. No, Street,

Contact Numbers

Trunk Line (with area code)

Barangay

Town/District/Municipality

Province/City

Area Code

Dept. of Pediatrics

Dept. of Obstetrics

Laboratory

Nursery/Pediatric
Ward

Fax Number

Email Address

Facility Classification
Ownership

Private
Government
Specialty Hospital

Level 1
Level 2
Level 3

Courier Information
Air21/Fedex
DHL/WWW
ABEST

LBC
LIBCAP

Others: Please Specify

Health Facility

Category A:
Primary Care
Infirmary/Dispensary
Birthing Home
RHU BHS

JRS
ABOITIZ

Category C:
Diagnostic/
Therapeutic

Category D:
Specialized
Out-Patient

Local Health Offices

PHO
MHO
CHO
CHD

If no courier is available in the area, specify

other means of transport of NBS Samples:
Hand Carry

Fax
Email
Courier

Statistics

Postal Money Order

Cash

Category B:
Custodial Care

Mode of Releasing NBS Result

Preferred Mode of Payment

Bank to Bank

Special Government

Postal Mail
Other:___________

Courier Preference

Zip Code

Mobile #

LGU

DOH Retained

Functional Capacity
General Hospital

Check

Philhealth Accreditation No.

Courier

Check

Cash

Annual Number of Deliveries

Newborn Screening Coordinators

The institution is requested to designate an NBS Coordinator and Assistant NBS Coordinator who will oversee the whole implementation of newborn screening in the institution and shall act as
the contact person of the Newborn Screening Center. All communications and supplies shall be addressed to the NBS Coordinator. Any changes on the NBS Coordinator should be
communicated properly to the NSC.
NBS Coordinator Name

NBS Assistant Coordinator Name

Mailing Address

Mailing Address

Contact Numbers (Office/Home/Clinic)

Fax

Contact Numbers (Office/Home/Clinic)

Fax

Mobile

Email

Mobile

Email

NBS Orientation Attended

No

Yes If yes, Date: ___/___/___

Organizer

Place

We hereby declare that all information stated herein is true and correct. Filling and submitting this form signify our readiness to offer newborn screening.
Sincerely,
Name and Signature

For NSRC Use Only (Do Not Fill)

Hospital Code
Date Processed

Position

Office

NSC Assignment
Processed by: