✨ Hospital Licensing Forms
SCHEDULE OF ROOMS AS SHOWN ON ATTACHED PLAN.
The numbers on the schedule must correspond with the numbers on the plan, and should be the same as will be used for identification of the rooms when in use.
| No. of Room as on Plan | Dimensions, &c. | Use to which the Room will be put. (In case of wards, whether medical and surgical or maternity. Otherwise state if for staff, family, service, or special use.) |
|---|---|---|
| Length. | ||
| Breadth. | ||
| Height. | ||
| Floor Area in Square Feet. | ||
| Ventilation and Window Area in Square Feet. | ||
| Heating. | ||
| Means of Communication, Electric Bells, &c. | ||
| Number of Persons to occupy Room. |
MAXIMUM NUMBER AND CLASS OF PATIENTS TO BE RECEIVED.
In accordance with this schedule and the plan attached I [We] propose to receive medical or surgical cases and maternity cases.
NURSING AND DOMESTIC STAFF.
In accordance with the regulations and this schedule and the plan attached I [We] have provided accommodation for and propose to keep the following staff, including the licensee [manager] [Cross out term which does not apply].
Registered nurses: Registered midwives:
Registered maternity nurses: Unregistered nurses:
Domestic helps:
Enclosed are two references as to character and fitness from
Signed [Applicant]. Address: Occupation:
Signed [Manager]. Address: Occupation:
Date:
(This space is reserved for use by Department.)
Hon. the Minister.
I approve of these premises being licensed in accordance with the above application as—
(a.) A licensed maternity hospital.
(b.) A licensed medical and surgical hospital.
(c.) A hospital licensed both as a maternity and as a medical and surgical hospital.
[Cross out lines which do not apply.]
Number of patients:
License granted.
No. of license:
Date:
ENDORSEMENTS OF LICENSE, ETC.
Changes authorized in the conditions approved according to this application form are to be briefly noted and signed by the authorizing or recording officer.
[For departmental use only.]
Date:
NOTIFICATION OF ABORTION OR MISCARRIAGE.
Name of Hospital: Address: Date:
The Medical Officer of Health,………
I HEREBY notify you that , of , was admitted to this maternity hospital on , suffering from the effects of abortion [miscarriage]. The name of the medical practitioner attending the patient is . Licensee or Manager.
NOTICE OF A PATIENT BECOMING MENTALLY DEFECTIVE.
Name of Hospital: Address: Date:
The Medical Officer of Health,………
I HEREBY notify you that , of , a patient at this licensed hospital, became mentally defective on , and has been removed to . The name of the medical practitioner attending the patient is . Licensee or Manager.
Next Page →
PDF embedding disabled (Crown copyright)
View this page online at:
VUW Te Waharoa —
NZ Gazette 1927, No 23
NZLII —
NZ Gazette 1927, No 23
✨ LLM interpretation of page content
🏥
Application Form for Private Hospital License
(continued from previous page)
🏥 Health & Social WelfarePrivate Hospital, License Application, Hospital Regulations, Health Facilities
🏥 Schedule of Rooms for Hospital License Application
🏥 Health & Social WelfareHospital Rooms, Schedule, Plan, Ventilation, Heating
🏥 Maximum Number and Class of Patients for Hospital License
🏥 Health & Social WelfarePatient Capacity, Medical Cases, Surgical Cases, Maternity Cases
🏥 Nursing and Domestic Staff for Hospital License
🏥 Health & Social WelfareNursing Staff, Domestic Staff, Hospital License, Accommodation
🏥 Approval of Hospital License Application
🏥 Health & Social WelfareHospital License, Approval, Minister, Patient Capacity
- Hon. the Minister
🏥 Endorsements of Hospital License
🏥 Health & Social WelfareLicense Endorsements, Changes, Departmental Use
🏥 Notification of Abortion or Miscarriage
🏥 Health & Social WelfareAbortion, Miscarriage, Notification, Medical Officer of Health
- Licensee or Manager
🏥 Notice of Patient Becoming Mentally Defective
🏥 Health & Social WelfareMental Defect, Patient Notification, Medical Officer of Health
- Licensee or Manager