Mu 32

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

S Y T NG THP
.

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc

, ngy
thng
BNG K KHAI C S VT CHT, THIT B Y T
CA C S KHM BNH, CHA BNH

nm 20

I. Phn k khai v c s vt cht ca c s khm bnh, cha bnh:

1. Din tch mt bng:..m2 (chiu di:. m, chiu rng. m).
2. Kt cu xy dng nh: Kin c , Bn kin c
, Nh tm
.
Nn:..........., vch..., trn ..
3. Din tch xy dng s dng.. m2; S tng ..
a. Bnh vin/Phng khm:
- Din tch trung bnh cho 01 ging bnh . m2.
- S khoa, phng, bung k thut chuyn mn, xt nghim, bung bnh.;
b. B tr cc khoa/chuyn khoa, phng;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
- Phng.., din tchm2, caom;
6. Cc iu kin v sinh mi trng:
a. X l nc thi....................................................................................... ;
b. X l rc y t, rc sinh hot .................................................................... ;
c. An ton bc x ....................................................................................... ;
7. H thng ph tr:
a. Phng chy cha chy ............................................................................ ;
b. Kh y t .................................................................................................. ;
c. My pht in......................................................................................... ;
d. Thng tin lin lc ................................................................................... .
8. C s vt cht khc (nu c);

II. Phn k khai v thit b y t ca c s khm bnh, cha bnh

STT

Tn thit b

K hiu thit b
(MODEL)

Cng ty sn Nc sn Nm sn
xut
xut
xut

S
Tnh trng
Gi thnh
lng s dng

Ghi ch

1
2
3

Ni nhn:
- Nh trn;
- Lu: VT, KHTH.

I DIN C S
(K tn v ng du)