✨ Hospital Licensing Application Form
JULY 7.] THE NEW ZEALAND GAZETTE.
PREMISES.
Estate or interest of applicant therein [If lease, give length of term] :
Site—Description of : Area of ground :
Plan of building as attached—Scale : inch to a foot. Aspect : Number of stories
Materials of building (brick, wood, &c.) :
Drainage :
Water-supply :
Fire escapes : Description : Position :
Fire-prevention appliances—Description : Position :
SANITARY AND SERVICE ROOMS.
Bathrooms—
For patients only—Nos. on plan : Fittings :
For staff only—Nos. on plan : Fittings :
Closets—
For patients only—Nos. on plan : Fittings :
For staff only—Nos. on plan : Fittings :
Sink-rooms—Nos. on plan : Size : x x Fittings :
Sterilizing-rooms—Nos. on plan : Size : x x Fittings :
Operating-theatres—
Nos. on plan : Size : x x Flooring : Windows : x
Heating : Lighting : Ventilation :
Fittings, &c. :
Labour wards—
Nos. on plan : Size : x x Flooring : Windows : x
Heating : Lighting : Ventilation :
Fittings, &c. :
Kitchen block and food-storage—Nos. on plan : Description :
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. | Length. | Breadth. | Height. | Floor Area in Square Feet. | Ventilation and Window Area in Square Feet. | Heating. | Number of Maternity, Confinement, Lietetic Beds, &c. | Number of Persons to occupy Room. | 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.) | (This space is for the use of the Department to note authorized changes in use of rooms, &c.) |
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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 undertake 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 :
[Each individual to be entered once only.]
Enclosed are two references as to character and fitness from
Signed [Applicant]. Address : Occupation :
Signed [Manager]. Address : Occupation :
Date : , 19 .
[This space is reserved for use by Department.]
Hon. the Minister.
Pursuant to section 128 of the Hospitals and Charitable Institutions Act, 1926, I approve of the above-described premises as suitable for the purposes of—
(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.]
subject to special restrictions and conditions endorsed hereon.
The premises are suitably equipped and furnished, and the means of escape in case of fire are adequate.
I recommend that you grant a license to the applicant, whose references as to character and fitness are satisfactory.
Number of patients : ……………, Director-General of Health.
License granted.
No. of license : ……………, Minister in Charge of Hospitals.
Date : , 19 .
SPECIAL RESTRICTIONS AND CONDITIONS SUBJECT TO WHICH THE WITHIN APPROVAL IS GIVEN.
Date : [For Head Office use only.]
F. D. THOMSON,
Clerk of the Executive Council.
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VUW Te Waharoa —
NZ Gazette 1932, No 46
NZLII —
NZ Gazette 1932, No 46
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🏥 Application Form for Hospital Licensing
🏥 Health & Social WelfareHospital licensing, Application form, Premises, Sanitary facilities, Patient accommodation, Staff requirements
- F. D. Thomson, Clerk of the Executive Council