Annex B.

1 Health Human Resource Survey Tool for PhilHealth Konsulta Provider

Name of Facility : Date of Assessment :

Address :

A. Physician: Total Number: Total Number of Hours per

Week:

PhilHealth Total Number

Accreditation Accreditation PRC License Date of
Name Member of Hours per
Number Validity Number Expiry
(Y/N) Week

B. Nurse: Total Number:

PhilHealth Member
Name PRC License Number Date of Expiry
(Y/N)

C. Midwife: Total Number:

PhilHealth Member
Name PRC License Number Date of Expiry
(Y/N)

Prepared : Attested Correct :

by by
Signature Over Printed Name Signature Over Printed Name

Designation Municipal Health Officer/ Chief of Hospital

Date Prepared Date Signed