S Y T NG THP

TRUNG TM Y T TP. CAO LNH

CNG HA X HI CH NGHA VIT NAM

_______________

S:
61 /KHTC.TTYT
V/v Hng dn th tc h s
ngh cp chng ch hnh ngh

c lp - T do - Hnh phc
____________________________

Tp. Cao Lnh, ngy 20 thng 03 nm 2014

Knh gi: - Trng cc Khoa, Phng trc thuc TTYT.

- Trng trm y t 15 x, phng
Cn c Quyt nh s: 617/Q-UBND-HC ngy 28/06/2013 ca UBND
tnh ng Thp Quyt nh cng b h thng cc th tc hnh chnh gii quyt
theo c ch mt ca, mt ca lin thng i vi lnh vc S Y t.
Thc hin cng vn s: 1515/SYT-NVY ngy 21/10/2013 ca S Y t
ng Thp v vic xc nhn qu trnh thc hnh khm bnh, cha bnh cho c
nhn hnh ngh v cp chng ch hnh ngh cho th trng rng; Thng bo s:
112/TB-SYT, ngy 22/10/2013 ca S Y t ng thp v vic Tiu chun trnh
chuyn mn c cp v khng c cp chng ch hnh ngh v giy php hot
ng khm bnh, cha bnh.
Nhm to iu kin thun li cho vic hon chnh b h s m bo tin
thc hin l trnh ng k cp chng ch hnh ngh v cp giy php hot ng
i vi c s khm, cha bnh trn a bn. Trung tm y t thnh ph Cao Lnh
ngh Trng cc Khoa, Phng, Trng trm y t 15 x, phng thc hin mt s
ni dung sau:
1. Biu mu h s cp chng ch hnh ngh:
1.1. Chng ch hnh ngh Y:
Thnh phn h s (01 b) bao gm:
a. n ngh cp chng ch hnh ngh (mu 01);
b. Bn sao c chng thc vn bng (hoc giy chng nhn trnh chuyn
mn i vi lng y hoc giy chng nhn bi thuc gia truyn hoc phng php
cha bnh gia truyn do B trng B y t hoc Gim c S Y t cp);
c. S yu l lch c xc nhn ca y ban nhn dn x, phng, th trn ni
c tr hoc xc nhn ca Th trng n v ni cng tc (mu 28);
d. Giy xc nhn qu trnh thc hnh (mu 29);
. Phiu l lch t php (Do s T php cp);
e. Hai nh 04 x 06cm c chp trn nn trng trong thi gian khng qu
06 thng tnh n ngy np n;
1.2. Chng ch hnh ngh Dc:
- n ngh cp chng ch hnh ngh theo mu do B Y t quy nh
(mu 1a/N-CC);

- Bn sao c chng thc cc vn bng chuyn mn;

- Giy xc nhn v thi gian thc hnh c s dc hp php do ngi
ng u c s (Trng trm y t hoc Gim c TTYT) cp theo mu do B y
t quy nh (mu s 3/GXN);
- Bn sao giy CMND c chng thc;
- Giy chng nhn sc khe do c quan y t c thm quyn cp trong thi
hn 12 thng;
- L lch t php (Do S T php cp);
- 02 nh mu (4x6cm) nn trng mi chp trong vng 6 thng.
2. Xc nhn qu trnh thc hnh:
2.1. Lnh vc Y:
- Trng hp c nhn hnh ngh KCB ang cng tc ti Trm y t trc
ngy 01/01/2012 c thm nin hnh ngh th vic xc nhn thi gian thc hnh
nh sau: Trng trm y t xc nhn cho ph trm v cc nhn vin ca trm y t
mnh ph trch; Ph trm xc nhn qu trnh thc hnh cho trng trm (theo
mu 29). Nhng Trm y t khng c ph Trm th giy xc nhn qu trnh thc
hnh ca Trng Trm y t do Ban Gim c S Y t xc nhn.
- Trng hp c nhn hnh ngh KCB ti cc khoa, phng ti Trung tm y
t: Trng phng khm k xc nhn mt bn v Gim c Trung tm y t k v
ng du mt bn (theo mu 29).
* Ghi ch: Phn xc nhn nng lc chuyn mn tng c nhn ghi nh sau:
+ Bc s: C kh nng thc hin cc k thut chuyn mn theo chuyn
khoa ng k thc hnh (vd: KCB Ni khoa, KCB Ngoi khoa, KCB Ngoi Sn,
KCB YHCT, KCB Nhi khoa...);
+ Y s a khoa, Y s sn nhi: C kh nng thc hin cc k thut chm sc
ngi bnh;
+ Y s YHCT: C kh nng thc hin cc k thut chm sc ngi bnh v
khm cha bnh YHCT;
+ NHS, c nhn NHS: C kh nng thc hin cc k thut chm sc ngi
bnh/ hoc ghi: thc hin chc nng n h sinh;
+ Y s rng tr em: C kh nng thc hin cc k thut rng tr em;
+ K thut vin phc hnh rng trung cp: C kh nng thc hin cc k
thut phc hnh rng;

2.2. Lnh vc Dc:

Giy xc nhn v thi gian thc hnh c s dc hp php do ngi
ng u c s (Trng trm y t hoc Gim c TTYT) cp theo mu do B y
t quy nh (mu s 3/GXN);
* Ph ch: thi gian xc nhn qu trnh thc hnh (lnh vc Y v Dc)
c quy nh ti iu 24, Lut khm cha bnh s 40/2009/QH12 thng qua ti
k hp th 6 kha XII ngy 23/11/2009.
3. Trnh t thc hin:
Sau khi hon tt h s, c nhn np h s v nhn giy hn ti b phn tip
nhn v tr kt qu ca S Y t tnh ng Thp.
4. L ph: (theo qui nh)
Yu cu th trng cc n v thc hin tt tinh thn cng vn ny./.
Ni nhn:
- Nh trn;
- Lu.

KT.GIM C
PH GIM C
( k )
L Th Tuyt Mai

Mu 01
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
__________________________

1 , ngy thng .. nm 20..

N NGH
Cp chng ch hnh ngh khm bnh, cha bnh
Knh gi: S Y t tnh ng Thp.
H v tn: ...................................................................................................................
Ngy, thng, nm sinh: ..
a ch ng k h khu thng tr: 2 ...
....
Giy chng minh nhn dn s: , cp ngy ../../..
Ni cp: ...
in thoi: .. Email ( nu c): ........................................
Vn bng chuyn mn: 3
nh km theo n ny gm cc giy t sau:
1. Bn sao c chng thc vn bng chuyn mn.
2. Giy xc nhn qu trnh thc hnh khm, cha bnh.
3. S yu l lch.
4. Phiu l lch t php (do S T php cp).
5. Hai nh chn dung mu (nn trng) 04cm x 06cm.
Knh ngh S Y t xem xt v cp chng ch ti c hnh ngh khm bnh,
cha bnh./.
NGI LM N
(K v ghi r h, tn)

________________
1. a danh.
2. Ghi r a ch theo ni ng k thng tr hoc tm tr..

3. Vn bng chuyn mn ghi theo i tng: Bc s, Y s, iu dng vin, H sinh vin, K

thut vin, Lng y; Giy chng nhn bi thuc gia truyn hoc Giy chng nhn phng php
cha bnh gia truyn.
Mu 28
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
nh
4x6

S YU L LCH

I. S lc l lch:
- H v tn: ........................................................................, B danh: ........................
- Ngy, thng, nm sinh: ..................................................., Nam/N:........................
- Ni sinh: ..................................................................................................................
- Dn tc: ................................................................ Quc tch: .
- Thng tr ti: .........................................................................................................
.....................................................................................................................................
- Ngh nghip: ............................................................................................................
- n v cng tc hin nay (nu l cn b, cng chc): .............................................
.....................................................................................................................................
II. Qu trnh o to, bi dng chuyn mn, nghip v:
Tn trng
Chuyn ngnh o T thng, nm
hoc c s o
to, bi dng
n thng, nm
to, bi dng

Hnh thc o
to, bi dng

Vn bng,
chng ch

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

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

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

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

...../..... - ...../......
...../..... - ...../......
...../..... - ...../......
...../..... - ...../......
...../..... - ...../......
...../..... - ...../......
...../..... - ...../......
...../..... - ...../......

* Ghi ch:
- Hnh thc o to, bi dng bao gm: Chnh qui, ti chc, chuyn tu, ...
- Vn bng bao gm: Tin s, thc s, bc s, dc s, c nhn, k s, cao ng, trung cp;

III. Qu trnh lm vic:

T thng, nm n
thng, nm

lm nhng cng vic g (k c hp ng lao ng) trong

c quan, n v, t chc no, u.

IV. Khen thng:

Thng, nm

Ni dung v hnh thc khen thng

Cp quyt
nh

L do v hnh thc k lut

Cp quyt
nh

V. K lut:
Thng, nm

Ngi khai
Ti xin can oan v nhng li khai
trong bn l lch ny l ng s tht
v chu trch nhim trc php lut.
..........., ngy..... thng...... nm ......
(k tn, ghi r h tn)

XC NHN
Bn l lch ny do .....................................
t khai ti ...................................................
l ng s tht.
UBND/C QUAN ....................................
(C quan nu ngi t khai l CB, CC, VC)
............, ngy ....... thng ........ nm ......

(k tn, ghi r h tn v ng du)

Mu 29
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)
................................................................
1
........................................................

CNG HA X HI CH NGHA VIT NAM

_______________

__________________________

S:

/GXNTH-............

c lp - T do - Hnh phc

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

GIY XC NHN QU TRNH THC HNH

....................3 xc nhn:
ng/b: ......................................................................................................................
Ngy, thng, nm sinh: ..............................................................................................
Ch hin nay:4 ............................................................................................
Giy chng minh nhn dn/H chiu s: ... Ngy cp: .....
Ni cp: ........................................
Vn bng chuyn mn: 5 .......................................... Nm tt nghip: .....................
thc hnh ti.6................................................................... v t kt qu nh sau:
1. Thi gian thc hnh: 7 ...................................................................................
2. Nng lc chuyn mn: 8 ...............................................................................
Trong thi gian cng tc khng c vi phm o c ngh nghip.
Ti hon ton chu trch nhim v xc nhn ny./.
TH TRNG N V
(k ghi r h, tn v ng du)

_____________________________________________________________________________
1. Tn c s khm bnh, cha bnh.
2. a danh.
3. i din c s khm bnh, cha bnh.
4. Ghi r a ch theo ni ng k thng tr hoc tm tr.
5. Ghi theo n ca ngi ng k thc hnh.
6. Ging nh mc 2.
7. Ghi ch th thi gian thc hnh t ngy .... thng ... nm ... n ngy ..... thng .... nm ....

8. Nhn xt v kh nng thc hin cc k thut chuyn mn theo chuyn khoa ng k thc hnh.

Mu 29
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)
TRUNG TM Y T TP. CAO LNH

CNG HA X HI CH NGHA VIT NAM

Trm y t ..............................

c lp - T do - Hnh phc

_______________

__________________________

S:

/GXNTH-TYT

, ngy thng nm 20

GIY XC NHN QU TRNH THC HNH

....................1..................... xc nhn:
ng/b: ..........................................................................................................
Ngy, thng, nm sinh: ..........................................................................................
Ch hin nay: 2 .......................................................................................
Giy chng minh nhn dn: Ngy cp: .
Ni cp: .........................................................................................................
Vn bng chuyn mn: 3 ....................................Nm tt nghip: ........................
thc hnh ti.4....................................................................... v t kt qu
nh sau:
1. Thi gian thc hnh: 5 ...............................................................................
2. Nng lc chuyn mn: 6 ...........................................................................
Trong thi gian cng tc khng c vi phm o c ngh nghip.
Ti hon ton chu trch nhim v xc nhn ny./.
TRNG TRM
(k ghi r h, tn v ng du)

i din c s khm bnh, cha bnh.

Ghi r a ch theo ni ng k thng tr hoc tm tr
3
Ghi theo n ca ngi ng k thc hnh.
4
Ging nh mc 2
5
Ghi c th thi gian thc hnh t ngy . thng nm. n ngy. thng .nm
6
Nhn xt c th v kh nng thc hin cc k thut chuyn mn theo chuyn khoa ng k thc hnh
2

Mu 29
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)
S Y T NG THP
TRUNG TM Y T TP. CAO LNH

CNG HA X HI CH NGHA VIT NAM

_______________

__________________________

S:

/GXNTH-TTYT

c lp - T do - Hnh phc

, ngy thng nm 20

GIY XC NHN QU TRNH THC HNH

....................1..................... xc nhn:
ng/b: ..........................................................................................................
Ngy, thng, nm sinh: ..........................................................................................
Ch hin nay: 2 ...........................................................................................
Giy chng minh nhn dn: Ngy cp: ....
Ni cp: .........................................................................................................
Vn bng chuyn mn: 3 ....................................Nm tt nghip: ........................
thc hnh ti.4....................................................................... v t kt qu
nh sau:
1. Thi gian thc hnh: 5 ...............................................................................
2. Nng lc chuyn mn: 6 ...........................................................................
Trong thi gian cng tc khng c vi phm o c ngh nghip.
Ti hon ton chu trch nhim v xc nhn ny./.
PHNG KHM A KHOA TPCL
TRNG PHNG

GIM C

i din c s khm bnh, cha bnh.

Ghi r a ch theo ni ng k thng tr hoc tm tr
3 Ghi theo n ca ngi ng k thc hnh.
4
Ging nh mc 2
5
Ghi c th thi gian thc hnh t ngy . thng nm. n ngy. thng .nm
6
Nhn xt c th v kh nng thc hin cc k thut chuyn mn theo chuyn khoa ng k thc hnh
7
Nhn xt c th v giao tip, ng x ca ngi ng k thc hnh i vi ng nghip v ngi bnh.
2

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

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

Mu s 1a/N-CC
Mu n ngh cp chng ch hnh ngh dc (cp ln u)
CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
.............1, ngy... thng . nm 20.....

N NGH
Cp chng ch hnh ngh dc
Knh gi: S Y t tnh ng Thp
H v tn: ......................................................................................................................................
Ngy, thng, nm sinh: ......................................................................................................................
Ni ng k h khu thng tr: ..
Ch hin nay:..............................................................................................................................
Giy chng minh nhn dn/H chiu s: .. . Ngy cp:.........................
Ni cp:..............................................................................................................................
in thoi: ................................................. Email ( nu c): ......................................................
Vn bng chuyn mn: .................................................................................................................
c thi gian thc hnh ti c s dc..
T ngy .......................n ngy...
n v cng tc cui cng.....................................
ngh cp Chng ch hnh ngh dc ng k l ngi qun l chuyn mn ca cc hnh thc
t chc kinh doanh sau 2:
1
2
3
4
5
6
7
8
9
10
11
12
13

Doanh nghip sn xut thuc

Doanh nghipsn xut vc xin, sinh phm
Hp tc x, h kinh doanh c th sn xut dc liu, thuc ng y, thuc t
dc liu
Doanh nghip bn bun thuc
Doanh nghip bn bun vc xin, sinh phm y t
Hp tc x, h kinh doanh c th bun bn dc liu, thuc ng y, thuc t
dc liu
i l bn bun vc xin, sinh phm y t
Nh thuc
Quy thuc
i l bn thuc ca doanh nghip
C s bn l thuc chuyn bn thuc ng y, thuc t dc liu
T thuc trm y t
Doanh nghip xut khu, nhp khu thuc

14
15
16
17

Doanh nghip lm dch v kim nghim thuc

Doanh nghip lm dch v bo qun thuc
Doanh nghip lm dch v bo qun vc xin, sinh phm y t
Doanh nghip lm dch v kim nghim vc xin, sinh phm y t

Sau khi nghin cu Lut Dc v cc quy nh khc v hnh ngh dc, ti xin cam
oan:
- Thc hin nghim tc v y cc quy nh hin hnh ca Lut Dc v cc vn bn
quy phm php lut v dc c lin quan;
- Thng xuyn quan tm nghin cu v nm vng cc vn bn v hnh ngh dc v
thc hin nghim chnh trong qu trnh hnh ngh;
- Ch ng k l ngi qun l chuyn mn hoc ch c s ca mt trong cc loi hnh
ghi trong Chng ch hnh ngh ti mt a im kinh doanh;
- Trong qu trnh hnh ngh, nu c thay i ti cam kt s lm cc th tc xin cp li
Chng ch hnh ngh dc, Giy chng nhn iu kin kinh doanh thuc.
Nu vi phm ti xin chu hon ton trch nhim trc php lut.
Knh ngh Qu c quan xem xt v cp chng ch hnh ngh dc cho ti.
.................., ngy

thng

nm

Ngi lm n

(K v ghi r h tn)

1. a danh;
2. nh du (X) vo hnh thc t chc kinh doanh ngh cp, c th nh du vo tt c cc
mc p ng quy nh.

Ti xin gi km theo n ny b h s gm cc giy t sau:

1.
2.
3.

4.

5.
6.

Bn sao c chng thc vn bng chuyn mn

Giy xc nhn v thi gian thc hnh c s dc hp php do ngi ng u
c s cp theo mu do B Y t quy nh 3
Bn sao c chng thc Giy chng minh nhn dn/h chiu nu h s gi bng
ng bu in (hoc bn chp v xut trnh bn gc i chiu nu h s np
trc tip)
L lch t php c c quan c thm quyn ca nc s ti xc nhn hoc Giy
php lao ng v Giy xc nhn l thnh vin Hi ng qun tr hoc Ban gim
c ca c s kinh doanh thuc (i vi ngi nc ngoi hoc ngi Vit Nam
nh c nc ngoi)
Giy chng nhn sc khe do c quan y t c thm quyn cp trong thi hn 12
thng;
Hai nh 04cm x 06cm

3. i vi Dc s tt nghip h Chuyn tu nu ch ng k loi hnh Nh thuc th khng cn c

xc nhn thi gian thc hnh

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

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

Mu s 3/GXN
Giy xc nhn thi gian thc hnh ti c s dc hp php
CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

GIY XC NHN
Thi gian thc hnh ti c s dc hp php
Tn n v .......................................................................................................................
Xc nhn ng/b...............................................................................................................
Thng tr ti...................................................................................................................
Chc v............................................................................................................................
.........................................................................................................................................
c thi gian cng tc ti..............................................................................................
.........................................................................................................................................
.........................................................................................................................................
Nhim v c phn cng:..............................................................................................
Trong thi gian cng tc khng c vi phm o c ngh nghip.
Ti xin chu hon ton trch nhim v xc nhn trn./.
.., ngy thng
nm
Th trng n v
(K tn, ng du)