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Mu 04

(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 HO X HI CH NGHA VIT NAM


c lp T do Hnh phc
................ 1, ngy

thng

nm 20....

N NGH
Thc hnh khm bnh, cha bnh
Knh gi: 2..
H v tn:
Ngy, thng, nm sinh: ........................................................................................
a ch ng k h khu thng tr:3 ..................................................................
.................................................................................................................................
Giy chng minh nhn dn s: ..................................., Cp ngy......../....../.......
Ni cp:................................
in thoi:.............................................. Email (nu c): ...................................
Vn bng chuyn mn: 4.......................................................................................
Khoa/ b phn chuyn mn ng k thc hnh: 5...............................................
Thi gian ng k thc hnh: .............................................................................
c iu kin c cp chng ch hnh ngh khm bnh, cha bnh, ti
ngh Gim c c s khm bnh, cha bnh cho php v to iu kin ti
c thc hnh khm bnh, cha bnh ti n v.
Ti cam kt s thc hin ng cc quy nh v vic thc hnh khm bnh,
cha bnh v cc quy nh khc ca c s khm bnh, cha bnh.
NGI LM N
(K v ghi r h, tn)

1. a danh
2. Ngi ng u c s khm bnh, cha bnh ni ngh ng k thc hnh.
3. Ghi r a ch theo ni ng k thng tr hoc tm tr.
4. Ghi theo i tng ngh cp chng ch hnh ngh: 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.
5. Ngi thc hnh ng k ph hp vn bng chuyn mn c o to.

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