Questionnaire

This questionnaire is aimed at collecting the information on your hospital, which will be used by
the JICA personnel in need for medical attention. Please kindly answer the following questions.

Questions about your facilities.

1. Name of your hospital / clinic.
RSU Mamami Kupang
2. Type of organization.
√
□ Government Private □Mission □Other ( )

3. Please write down address ,telephone/fax number of your hospital/clinic.

Address : Jl. RW Monginsidi 1 No.3 Kelurahan Pasir Panjang Kecamatan Kota Lama
Kupang- Nusa Tenggara Timur
Telephone:0380 (806194) Fax number :-
4. Do you have a website of Hospital ?
√
□ Yes □No

5 List of the departments of diagnosis and treatment.Please tick below.

√
□Internal medicine □Otorhinolaryngology

□Cardiology □Ophthalmology

□Gastroenterology □Dermatology

√
□Neurology □Pediatrics

√
□General surgery □Obstetrics and gynecology

□Surgery of Gastroenterology □Psychiatry/psychology

□Cardiac surgery □Radiology

□Orthopedics □Anesthesiology

□Neurosurgery □Dentistry

□Urology □Others ( )

6. How many beds do you have for in-patients.? 44 beds

7 Average number of the outpatients a day outpatients
8. How many doctors and nurses are working in your hospital? 22 Doctors. 20 Nurses
9. How many Lab. technologists, radiological technologists and pharmacists are working in your
hospital?
Lab. technologists 5 Radiological technologists 0 , Pharmacists 4
10. What kind of medical units do you have? Please tick the followings.
√ √
□Operation room □Emergency room □Intensive care unit

√
□Blood bank □Laboratory room □X-ray room

√
□Hemodialysis unit □Pharmacy □Private room for In-patient

11. Please
√ let us know your consultation hours and days.

● Days From to .

● Hours From to .

□ 24-hour open.

12. Are your patients required to make appointments for visit your doctors?
√
□Yes □No

Contact telephone number.

13. Do you accept emergency cases?
√
□Yes□No

Contact telephone number.

14. Do you have your own transportation services for an emergency patient?

□ Yes □No

□ Ambulance (car) □Helicopter □Others

15. Are the following tests carrying out in your hospital for blood transfusion?
Please tick below.

●Blood type
√
√
□ABO Group □R h □Cross matching
 ●Compulsory test

√
□Hb □HBs-Ag□HCV-Ab□HIV-Ab□ Syphilis□Chagas

√
□Brucellosis□Malaria□Other

●How long does it take to complete the lab.tests when you get blood donation in the event of

emergency ?
√
□ 2hours □6hours □12hours □More than 24 hours

●What kind of blood transfusion are available in your hospital?

□Whole blood□Fresh frozen Plasma(FFP)□Concentrated platelet

□Red cells

16. Are the following vaccinations available in your hospital? Please tick below.

□Polio-oral □Polio-injection □BCG □DPT

□Mumps □Measles □Chicken pox □MMR

√
□Tetanus Toxoid □Hepatitis A □Hepatitis B □Rabies

□Cholera □Yellow fever □Typhoid -oral □Typhoid -injection

□Meningitis□Japanese encephalitis

□Influenza(Hib)□Tick borne encephalitis

□Others
17. What medical examinations are available in your hospital? /Please tick the followings.
Hematology Serology X-ray
√ Complete Blood Count CRP chest
□ □ □

WBC-Differential HBs-Ag abdomen

□ □ □

ESR HBs-Ab Barium GI series

□ □ □

Bio- Chemistry HCV-Ab Barium Colon

□ □

√ AST(GOT) HA-Ab IV retrograde urography

□ □ □

√ ALT (GPT) HIV(1,2)-Ab Screening CT Scan

□ □

γ-GTP TPHA Head

□ □ □

LDH VDRL Whole body

□ □ □

√ T-Bilirubin Filaria-Ab MRI

□ □

ALP Schistosoma japonicum-Ab MRI

□ □ □

√ Total protein S.mansoni-Ab Ultrasound

□ □

√ Albumin S. haematobium-Ab Abdomen

□ □ □

√ Blood Sugar √ Widal test Heart

□ □ □

HbA1c Brucellosis-Ab Pelvis

□ □ □

√ T- Cholesterol Malaria Endoscopy

□

√ LDL Cholesterol √ RDT Upper GI

□ □ □

√ HDL Cholesterol QBC Colon

□ □ □

Triglyceride MPS Bronchus

□ □ □

√ Urea Nitrogen Dengue Microbiology

□
 √ Creatinine NS1Ag √ Smear
□ □ □

Uric Acid Dengue IgM Culture/Sensitivity

□ □

Amylase Dengue IgG √ Urine

□ □ □

Urine examination Tuberculosis Stool

□

√ Protein Sputum Smear Blood

□ □ □

√ Glucose Sputum for AFFB Sputum

□ □ □

√ Occult Blood PCR ECG

□ □

√ Sediments IGRA test ECG(rest)

□ □ □

Stool examination Exercise ECG

□ QFT-3G □

Occult Blood Holter ECG

□ □ T-Spot.TB □

Parasites EEG
□

EEG
□

Eye examination
Ophthalmoscopy
□

Thank you very much for your cooperation.