Act No: CAP. 253
Act Title: MEDICAL PRACTITIONERS AND DENTISTS
SUBSIDIARY LEGISLATION
Arrangement of Sections
THE MEDICAL PRACTITIONERS AND DENTISTS (ELECTION OF MEMBERS OF THE BOARD) RULES

ARRANGEMENT OF RULES

1.

Citation

2.

Interpretation

3.

Notice of election to the Board

4.

Nomination of candidates

5.

Election where nominations do not exceed vacancies

6.

Voting procedure

7.

Counting of votes and elections of candidates

8.

Appeals

SCHEDULES

FIRST SCHEDULE [r. 4] —

FORM

SECOND SCHEDULE [r. 6] —

VOTING PAPER

THE MEDICAL PRACTITIONERS AND DENTISTS (ELECTION OF MEMBERS OF THE BOARD) RULES
1.
Citation

These Rules may be cited as the Medical Practitioners and Dentists (Election of Members of the Board) Rules.

2.
Interpretation

In these Rules, "Returning Officer" means a person appointed by the Board for the purposes of these Rules.

[L.N. 209/1983, r. 2, L.N. 216/1994, r. 2(a).]

3.
Notice of election to the Board
(1)

The Cabinet Secretary may, from time to time, by notice in the Gazette and in such newspapers circulating in Kenya as he may think fit, declare that an election to the Board of up to the five medical practitioners and two dentists prescribed under paragraph (f) of subsection 4(1) of the Act shall be held on a day to be specified in the notice, which day is in these Rules referred to as "election day".

(2)

The notice shall be so published at least ninety days before election day except in the case of the first election of such members in respect of which notice may be given at any time before election day.

4.
Nomination of candidates
(1)

Each medical practitioner or dentist registered in Kenya may, in the form set out in the First Schedule, nominate one registered medical practitioner or dentist, as the case may be, as a candidate for election to the Board;

Provided that nobody shall nominate himself as a candidate.

(2)

The nomination paper shall contain in block letters the full names of both the proposer and of the candidate and their signatures, which signatures shall be made in the presence of a registered medical practitioner or dentist, as the case may be, of at least five years’ practical experience in Kenya as indicated in the form; and the paper shall also be signed by five registered medical practitioners in support of a candidate for election to the Board as a medical practitioner or three registered dentists in support of a candidate for election to the Board as a dentist.

(3)

Each nomination paper, when completed in accordance with paragraph (2), may be either delivered in person to the office of, or sent by registered post to, the Returning Officer in time for it to be received by the Returning Officer not later than thirty days before election day.

(4)

No nomination paper shall be valid unless the provisions of this rule have been strictly complied with and the candidate has indicated his willingness to stand for election.

(5)

Any nomination form received by the Returning Officer which does not comply with the provisions of paragraph (2) or which is not received within the time prescribed under paragraph (3) shall be rejected by the Returning Officer but shall be kept and be available for inspection by an interested party for a period of at least six months after the election day to which it relates.

5.
Election where nominations do not exceed vacancies
(1)

If the number of persons correctly nominated for either profession under rule 4 of these Rules does not exceed the number of vacancies specified in the notice published under rule 3, all the persons nominated for that profession shall be deemed to have been elected and the names shall be published in accordance with the provisions of paragraph (4) of rule 7 of these Rules.

(2)

If the number of the persons nominated for either profession exceeds the vacancies on the Board in respect of that profession, the voting prescribed in rule 6 of these Rules shall be followed.

6.
Voting procedure
(1)

In the event of an election having to be held, the Registrar shall not later than twenty-one days before election day send by registered post to every medical practitioner or dentist, as the case may require, registered in Kenya, a voting paper in the form set out in the Second Schedule which shall contain the names of all candidates who have been duly nominated in accordance with rule 4 together with a suitably addressed envelope for returning the voting paper.

(2)

Each medical practitioner or dentist who receives a voting paper may, if he wishes to record his vote, place an X against the names of such candidates (not exceeding the number in respect of his side of the profession specified in the notice published under rule 3) for whom he wishes to vote, and shall sign and date the voting form and write his full name in capital letters in the spaces provided for that purpose; and a voting paper which does not contain those particulars, or which contains more than those particulars, may be treated as a spoilt voting paper and, if so treated, shall not be taken into account for the purposes of the election.

(3)

The voter shall then return the voting paper in the special envelope sent to him, which shall be sealed before it is despatched by delivering it personally or by sending it by registered post to the Returning Officer at the address appearing on the envelope.

(4)

A voting paper received by the Returning Officer after noon on election day shall not be opened by him until after the election has been completed and the results have been published in accordance with rule 7, but shall be kept and be available for inspection by an interested party for a period of at least six months after the election day to which it relates.

(5)

Personal canvassing for a candidate within the medical or dental professions by any reasonable means shall not disqualify a candidate, but canvassing by posters, press or other mass media or advertisements shall lead to a candidate being disqualified.

[L.N. 216/1994, r. 2(b).]

7.
Counting of votes and elections of candidates
(1)

After 4.30 p.m. on election day, the Returning Officer shall, in the presence of the Registrar, a Deputy Director of Medical Services, one registered medical practitioner and one dentist nominated by the Returning Officer, count the votes given for each candidate, and shall forthwith declare those candidates, not exceeding the number of vacancies to be filled, who receive the highest number of votes to be duly elected to the Board.

(2)

Candidates or their authorized representatives may be present at the counting of the votes if they so wish.

(3)

Election shall be by a simple majority but in the event of a tie, the succesful candidate shall be determined by a lot drawn by the Returning Officer in such manner as he shall decide.

(4)

The names of the successful candidates shall be published within fourteen days after election day in a notice in the Gazette and in such newspapers circulating in Kenya as the Returning Officer may think fit.

8.
Appeals

A person aggrieved by a decision of the Returning Officer on an election matter may appeal to the Cabinet Secretary within fourteen days of the publication of the results of the election in the Gazette and on any such appeal the Cabinet Secretary may annul the election or may vary any decision of the Returning Officer in such manner as he may think fit.

FIRST SCHEDULE

[r. 4]

FORM

Serial No. .........................

CounterfoilSerial No. ..............

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

NOMINATION PAPER

Nomination of a candidate for election to the Board.

Name and address of nominated candidate in full (block letters) and

Registration No. .............................................................

Name and address of proposer in full (block letters) and Registration No. ..............

Signature of proposer .............................................................

Signed by the above-named ................................................ (proposer)

in my presence this .............. day of .................. 20 ............

Full Name (BLOCK LETTERS), Address

.......................................

and Registration No. .................

(Registered Medical/Dental* Practitioner

.......................................

of not less than five years experience in

.......................................

Kenya)

Full Names (BLOCK LETTERS)

Address

Reg. No.

Signatures

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

...................

of not less than five supporters (who must be medical practitioners in the case of a candidate who is a medical practitioner); or

Full Names (BLOCK LETTERS)

Address

Reg. No.

Signatures

......................

...................

...................

...................

......................

...................

...................

...................

......................

...................

...................

...................

......................

...................

...................

...................

of not less than three supporters (who must be dentists in the case of a candidate who is a dentist).

I agree to accept this nomination

Signature of candidate ....................................................

Signed by the above-named ........................................... (candidate)

in my presence this ........................ day of ..................., 20........

Full Name (BLOCK LETTERS), Address

.......................................

and Registration No. .................

(Registered Medical/Dental* Practitioner

.......................................

of not less than five years experience in

.......................................

Kenya)

*Delete where applicable

SECOND SCHEDULE

[r. 6]

VOTING PAPER

CounterfoilSerial No. .......

Serial No. ...........

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

VOTING PAPER-MEDICAL PRACTITIONERS

Names of Candidates

Here insert X against names of candidates for whom you wish to vote

Name and address of voter in block letters and Registration No. ..................

Signature of voter ........................................................

Date ......................................................................

CounterfoilSerial No. .......

Serial No. ...........

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

VOTING PAPER-DENTISTS

Names of Candidates

Here insert X against names of candidates for whom you wish to vote

Name and address of voter in block letters and Registration No. ..................

Signature of voter ....................................................

Date ..................................................................

1.

These Rules may be cited as the Medical Practitioners and Dentists (Forms and Fees) Rules, and shall be deemed to have come into force on the 1st January, 1978.

2.

The register of medical practitioners and dentists to be maintained by the Registrar in accordance with section 5(3) of the Act, shall be in Form I in the First Schedule to these Rules.

3.

Application for registration as a medical or dental practitioner in accordance with section 6(1) of the Act shall be in Form II in the First Schedule to these Rules.

4.

The certificate of registration to be issued by the Registrar in accordance wFith section 7 of the Act shall be in Form III in the First Schedule to these Rules.

5.

Application for a licence to render medical or dental services in accordance with section 13 of the Act shall be in Form IV in the First Schedule to these Rules.

6.

A licence issued to render medical or dental services in accordance with section 13 of the Act shall be in Form V in the First Schedule to these Rules.

7.

Application for a licence for private medical or dental practice in accordance with section 15(1) of the Act shall be in Form VI in the First Schedule to these Rules.

8.

A licence for private medical or dental practice in accordance with section 15(2) of the Act shall be in Form VII in the First Schedule to these Rules.

8A.

The Board may charge additional late application fee of five hundred shillings in respect of applications submitted out of time under rules 4(2), 7(2) and 28(2) of the Medical Practitioners and Dentists (Private Practice) Rules.

9.

Application for recognition of specialist or sub-specialist status shall be in Form VIII in the First Schedule.

10.

The fees set out in the Second Schedule shall be payable in respect of the matters set out therein.

11.

Application for registration of a medical institution in accordance with rule 4(1) of the Medical Practitioners and Dentists (Medical Institutions) Rules shall be in Form IX set out in the First Schedule to these Rules.

12.

The certificate of registration to be issued by the Registrar in accordance with rule 4(3) of the Medical Practitioners and Dentists (Medical Institutions) Rules shall be in Form X set out in the First Schedule to these Rules.

13.

Application for a licence to operate an approved medical institution in accordance with rule 5(1) of the Medical Practitioners and Dentists (Medical Institutions) Rules shall be in Form XI set out in the First Schedule to these Rules.

14.

The annual fees assessment form prescribed in rule 5(3) of the Medical Practitioners and Dentists (Medical Institutions) Rules shall be in Form XII set out in the First Schedule to these Rules.

15.

A licence issued to operate an approved medical institution in accordance with Rule 5(4) of the Medical Practitioners and Dentists (Medical Institutions) Rules shall be in Form XIII set out in the First Schedule to these Rules.

16.

The Board shall when inspecting outpatient medical institutions pursuant to rule 11 of the Medical Practitioners and Dentists (Medical Institutions) Rules use the checklist in Form XIV set out in the First Schedule.

17.

The Board shall when inspecting inpatient medical institutions pursuant to rule 11 of the Medical Practitioners and Dentists (Medical Institutions) Rules use the checklist in Form XV set out in the First Schedule.

[L.N. 76/1983, r. 2, L.N. 26/2000, r. 2, L.N. 75/2012, r. 2, L.N. 4/2017, r. 2, 4, 5, 6, 7, 8.]

FIRST SCHEDULE

FORMS

[L.N. 76/1983, r. 2, L.N. 26/2000, r. 2, L.N. 161/2015, r. 2.]

FORM I

(r. 2)

REGISTER OF MEDICAL PRACTITIONERS AND DENTISTS

No.

Full Name

Address

Basic Qualification

Date of Registration

Additional Qualifications

Date and No. of original Registration

Remarks

________________________

FORM II

(r. 2(a))

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR PERMANENT REGISTRATION AS A MEDICAL OR DENTAL PRACTITIONER

1.

Surname ................. First Name............. Other Names ...........

2.

Date of Birth ........................ Nationality .......................

3.

ID No./Passport No. ............................................

4.

Address ...... Code ...... Town .... County ..... Cell Phone .........

5.

Email ..............................................

6.

Degree, Diploma or licence held .......... Date(s) qualified .......

7.

Name of medical/dental school ............... Email ................

8.

Name of Internship Training Centre ........... Email ...........

Period of internship from ............................. to ........................

9.

Particulars and testimonials covering the period of experience .........

10.

Name of employer ....................................................

Address .................. Code .........Town .......County............

Email ......................... Tel ...........................

Requirements:

(i) Copy of ID/Passport;

(ii) Coloured passport size photo;

(iii) Certfied copies of professional & academic certificates;

(iv) Evidence of passing Board's pre-registration examination;

(v) Internship completion Assessment Forms dully filled and stamped;

(vi) Evidence of registration from EAC Partner States' Boards and councils (for those applying for reciprocal registration);

(vii) Registration Fee KSh. 8,000.00

All payments should be made at any KCB Branch countrywide to Board's account No. 1103158643 Milimani Branch. SWIFT CODE: KCBLKENX, BANK. KCB, BANK CODE: 01175.

I hereby certify that the above information is correct to the best of my knowledge and that I have met the above requirements.

Signature of Applicant: .................................... Date ..................

FOR OFFICIAL USE

The process will take a maximum of two weeks.

PREPARED

APPROVED/NOT APPROVED

Name: .................................Designation ....................................Signature ......................................Date ..............................................RECOMMENDED:Name: .........................................Designation .................................Signature .................................Date ..........................................

Name ...............................................Designation .....................................Signature .........................................Date ................................................

________________________

FORM III

(r. 4)

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

CERTIFICATE OF REGISTRATION AS A MEDICAL PRACTITIONER OR DENTIST

Registration No. ......................

Dr./Mr/Mrs./Miss* ..................................................

................................................... (full names BLOCK LETTERS) has been registered as a Medical/Dental* Practitioner in accordance with the provisions of section 6 of the Medical Practitioners and Dentists Act (Cap. 253).

Dated this ............... day of .................., 20 ............

Seal of the Board.

..............................................ChairmanMedical Practitioners and Dentists Board

...............................................Registrar ofMedical Practitioners and Dentists

*Delete where not applicable.

________________________

FORM IVA

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR MEDICAL AND DENTAL PRACTITIONERS INTERNSHIP LICENCE

1.

Surname .................... First name ....................... Other names ...............

2.

Date of Birth ......................... Nationality ............................

3.

Address ................. Code .................... Town ............... Tel ..............

Email ...............................................................

4.

Degree, Diploma or Licence held (if degree not in English provide official translation)

...................................................................

5.

Name of Medical/Dental School ................... Address ............... Code ...............

Email ......................................................

6.

Name of Internship Training Centre .................. Address ............ code .............

Email .........................................................

Requirements:

(i) Copy of ID/Passport;

(ii) Coloured passport size photograph;

(iii) Evidence of passing Board Internship Qualifying Exam (foreign trained);

(iv) Copy of posting letter from the Ministry of Health;

(v) Evidence of completing Medical/Dental Training in an accredited University in Kenya;

(vi) Evidence of having completed Medical/Dental Training in an institution within the EAC that qualifies for reciprocal recognition;

(vii) Licence fee KSh. 5000.

I hereby certify that the above information is correct to the best of my knowledge and I have met the above requirements.

Signature of applicant ................................ Date ..........................

FOR OFFICIAL USE:

The process takes a maximum of two (2) weeks

PREPARED BY

APPROVED/NOT APPROVED

Name: ................................. Designation .........................Signature .............................. Date ....................................CHECKED BY:Name: ................................. Designation .........................Signature .............................. Date ....................................

Name ....................................Designation .............................Signature ..............................Date .....................................

________________________

FORM IVB

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

INTERNSHIP LICENCE FOR MEDICAL AND DENTAL PRACTITIONERS

Dr. .................................................................................

(full name)

of ..................................................................................

(address)

Qualifications..........................................................................

Is hereby licensed by the Medical Practitioners and Dentists Board to render Medical services at .......................................

(name of approved institution)

In accordance with the provisions of section 13 of the Act.

Dated the ............................. 20 ...............................

.........................................................

Registrar

Medical Practitioners and Dentists Board

CONDITIONS OF LICENCE:

1.

This licence is valid for a period of 11 MONTHS from the date hereof.

2.

The licensee is authorized to render medical or dental services as the case may be, only at the institution mentioned in this licence.

3.

The licence is entitled to engage in training employment.

4.

This licence does not entitle you to engage in private practice.

5.

Signature of Holder ...................................................

________________________

FORM VA

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

APPLICATION FOR RETENTION IN THE YEAR .............. REGISTER

(ALL DOCTORS)

(All fields are mandatory)

1.

Surname ........................... Other Names .......................

Reg. No. ...............................................................

2.

Date of Birth ........................ Nationality .....................

3.

Address .................. Code ............... Town ............... Mobile No ..................

4.

Email ....................................................................

5.

Name of Employer .................. Address ............ Code ......... Town .............

Email ..................................................................

6.

Work station .................. County .................. Sub-County.

7.

Basic Qualifications .................... Postgraduate qualifications ..................

8.

Recognized Speciality ............................... Sub Specialty ...............................

Requirements:

(a)

Acquire a minimum of 50 CPD points in the calendar year

(b)

Evidence of employment if practitioner is not in private practice

(c)

Renewal fee Kshs. 4,000

All payments should be made to:

Medical Practitioners and Dentists Board

Account No: 1103158643,

Bank: KCB, Milimani Branch.

SWIFT CODE: KCBLKENX

BANK CODE: 01175

*Transactions can be undertaken at any KCB Branch countrywide

(d)

Late payment will attract 50% penalty. Penalty date is 30th September ............

Computer generated and stamped banking slip together with should be, within the first week, either emailed to info@kenyamedicalboard.org or posted to Medical Practitioners and Dentists Board Office.

I hereby certify that the above information is correct to the best of my knowledge and I have fulfilled all the above requirements.

Signature .................................. Date .............................

FOR OFFICIAL USE

PREPARED

APPROVED/NOT APPROVED

Name: ................. Designation ............ Name ...........................

Signature .................. Date ................ Designation ....................

RECOMMENDED:

Name ............... Designation .............. Signature .........................

Signature ............... Date ................... Date ...................

Physical Address: MP & DB House-, Woodlands Road, off Lenana RoadAddress: P. 0 Box 44839-00 100, NAIROBI — KenyaErnail: info@kenyamedicalboard.org

Tel: +254 20-272 8752 /+254 20 272 4994 /+254 20 271 1478Mobile: +254 720771478/+254 736771478Website: www.medicalboard.co.ke

________________________

FORM VB

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

ANNUAL RETENTION CERTIFICATE

Date of first registration (date) Registration No. (Reg. No.)

This is to certify that ..................................................................

Whose qualifications are: ........................................... (Qualifications)

And whose registered address is: .......................................... (Address)

Having duly complied with the provisions of the Medical Practitioners and Dentists Board is entitled to practice during the year (year).

A retention certificate must be renewed for very subsequent year. This confirmation is evidence of retention in the Register only until 1st December (year).

This certificate does not allow the holder to engage in Private practice.

Seal of the Board.

Dated ........................... 20 ................

(Signature)

.................................. (DMS) ........................................

Registrar, Medical Practitioners and Dentists Board.

________________________

FORM VI

Serial No. .................................

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR REGISTRATION OF A PRIVATE MEDICAL INSTITUTION

PART I

(To be completed by the applicant in duplicate)

1.

CONTACT DETAILS OF THE PROPOSED INSTITUTION

(Block Letters)

(a)

Name of the Institution ................. Address .....................

(b)

Telephone Number ................... Mobile ..........................

(c)

Email .................................................

2.

TYPE (State whether Hospital, Nursing Home, Maternity Home, Health Centre, Dispensary, Laboratory, etc.).

........................................................................

3.

LOCATION OF THE INSTITUTION

(a)

Town/Centre/Market ............................................

(b)

Location ...........................................................

(c)

County .............................................................

PART II

(To be completed by the applicant in duplicate)

1.

FULL NAMES AND ADDRESS OF THE APPLICANT

(Block Letters)

.......................................

STATE IF APPLICANT IS A DIRECTOR AND/OR ADMINISTRATOR OF THE INSTITUTION

.............................................................................

*Delete where inapplicable

2.

NATIONALITY OF THE APPLICANT

.....................................................................

3.

PLACE AND DATE OF BIRTH .....................................................

4.

NATIONAL IDENTITY CARD No. ..........................................

(Attach Photocopy)

5.

PASSPORT No. (if applicable) ...............................

ADDRESS.............................................................

6.

WORK PERMIT No. (if applicable)

.....................................................................................

(Attach documentary evidence-copies only).

PART III

(To be completed by the applicant in duplicate)

Give full names of Directors of the institution including the following: Nationalities, Passport Numbers, Work Permit Numbers, Email Address, Kenya National Identity Card Numbers, etc.

(Attach copies of documentary evidence).

(i) ...........................................................
(ii) ..........................................................
(iii) ............................................................
(Use extra space if necessary).

PART IV

(To be completed by the applicant in duplicate)

1.

Give full names and registration number of the medical or dental practitioner who shall be in-charge of the patient health care at the proposed institution:

...............................................................................................

....................................................................................................

2.
(a)

Give full details of professional qualifications of the person named at paragraph (1) above. Include year and place where obtained;

(b)

State work experience of the person named at paragraph (1) of PART IV above and name institutions where obtained and date;

(c)

Attach documentary evidence (photocopies) in each case. (Please use extra space if necessary).

.................................................

3.
(a)

Give full names and professional qualifications of any other person(s), identified by your institution to undertake patient health care at the institution (e.g., Clinical Officers, Nurses, Laboratory Technicians, X-ray Staff, Doctors, Technicians, Pharmaceutical Technicians, etc.).

(b)

Attach documentary evidence (photocopies) in each case. (Please use extra space if necessary).

(i) ..........................................................................
(ii) ..........................................................................
(iii) .........................................................................
(iv) .........................................................................
(v) ..........................................................................
(vi) .........................................................................

PART V

(To be completed by Medical Officer of Health in duplicate)

INSPECTION REPORT FOR PRIVATE MEDICAL INSTITUTIONS - FOR REGISTRATION PURPOSES
1.

NAME OF THE INSTITUTION ...................................

2.

PHYSICAL LOCATION

(a)

Plot No./L.R. No .............................................................

(b)

Market/Centre/Town* .....................................................

(c)

Street/Road .................................................................

(d)

Location ......................................................................

(e)

County ........................................................................

3.

PREMISES GENERAL INFORMATION

(a)

Plot area (in hectares) ..........................................

(b)

Water supply ..................................... adequate/inadequate*

(*Delete where inapplicable)

(c)

Refuse disposal:

(i) Incinerator available/Not available.*
(ii) Other modes of refuse disposal (Specify) ......................................................
(d)

Environmental suitability ................. recommended/not recommended.

*State reasons for not recommending:

.............................................................

4.

PLAN OF THE INSTITUTION

(a)

Approved/No approved* by the local District Development Committee (attach copy of the plan) and documentary evidence (copies) of approval of the institution by the D.D.C

5.

OUT-PATIENT SERVICES

(See attached minimum requirements for General Practice).

(a)

Waiting Bay/Reception Area/Room:*

(i) Seating capacity ......................................................
(ii) Area (in square metres) ...........................................
(iii) Construction .......................................... Covered/ Not Covered.*
(b)

Examination Rooms:

(i) Number of rooms ...................................................
(ii) State if equipment inspected meets the minimum requirements. Attach separate signed list of equipment inspected if necessary. ..................................................................
(c)

Treatment room:

(i) Number of rooms ...................................................
(ii) State if equipment meets the minimum requirements. Attach separate signed list of equipment inspected.

*Delete where inapplicable

6.

IN-PATIENT SERVICES

(a)

Female Ward:

(i) Size of the ward (in square metres) .................................
(ii) Number of beds ..............................................................
(iii) Number of toilets ...........................................................
(iv) Number of bathrooms ...................................................
(v) Number of sluice rooms .................................................
(b)

Male Ward:

(i) Size of the ward (in square metres) .................................
(ii) Number of beds ..............................................................
(iii) Number of toilets ...........................................................
(iv) Number of bathrooms ...................................................
(v) Number of sluice rooms .................................................
(c)

Maternity Ward:

(i) Size of the ward (in square metres) .............................
(ii) Number of beds .........................................................
(iii) Number of toilets ...................................................
(iv) Number of bathrooms ...................................................
(v) Number of sluice rooms ...............................................
(vi) Placenta pit depth (in metres) .....................................
(d)

Paediatric Ward:

(i) Size of the ward (in square metres) ..................................
(ii) Number of beds .......................................................
(iii) Number of toilets ......................................................
(iv) Number of bathrooms .........................................................
(v) Number of sluice rooms ....................................................
7.

CLINICAL SUPPORT SERVICES

(a)

Pharmacy:

(i) Area of the waiting room (in square metres) ...............................
(ii) Number of dispensing windows ................................................
(iii) Number of antibiotic (safe cupboards) ....................................
(iv) Number of drug stores ......................................................
(b)

Laboratory:

(see attached minimum requirements)
(i) Reception area (in square metres) ............................................
(ii) Seating capacity ....................................................
(iii) Size of work-room (in square metres) ......................................
(iv) Equipment (attach a separate signed list of equipment and reagents/chemicals inspected).
(c) X- ray Unit:
(See attached minimum requirements).
(i) Size of the reception area (in square metres) .................................
(ii) Seating capacity ...................................................................
(iii) Number of screening rooms ......................................................
(iv) Standard of radiation protection ................................................
Adequate/Not Adequate.*
(v)

Equipment (attach separate signed list of equipment inspected).

(d)

Operating Theatre:

(i)

Minor theatre equipment (attach separate signed list of equipment inspected).

(ii)

Major theatre (indicate by a tick or cross in the box next to the item to show whether available or not).

Induction room ............................... ☐

Operating room ............................... ☐

Recovery room ................................ ☐

Lighting ............................. (Adequate/Not Adequate).*

Equipment ........................ (attach separate signed list of equipment inspected).

8.

OTHER SUPPORTING SERVICES

(a)

Kitchen;

(i) Cooking facility (specify) ............................
(ii) Non-Perishable store ........................ (Adequate/Not Adequate).*
(iii) Perishable store .............................. (Adequate/Not Adequate).*
(b)

Laundry Type (specify) ..............................

(c)

Mortuary:

(i) Available/ Not Available.*
(ii) Refrigerated/ Not refrigerated.*
(iii) Appropriately located /Not appropriately located.*
(If not appropriately located, state why)
(iv)

Body capacity ..........................................

(v)

Adequate privacy /Not adequate privacy.*

(vi)

Number of ambulances ....................................

(vii)

Other facility (specify and use extra space if necessary) ........................

*Delete where inapplicable

PART VI

(To be completed by the applicant in duplicate)

1.

Give full names and designations of members of the D.H.M.T who participated in the inspection of the institution.

NAME

DESIGNATION

(i) .................................................

.................................................

(ii) .................................................

.................................................

(iii) .................................................

.................................................

(iv) .................................................

.................................................

(v) ..................................................

...............................................

(vi) .................................................

.................................................

(vii) .................................................

.................................................

(viii) .................................................

.................................................

(ix) .................................................

.................................................

(x) .................................................

.................................................

2.

CERTIFICATE BY M.O.H

I, Dr ............................................................................

State full names in Block Letters)

being the Medical Officer of Health in ........................................

County, do hereby certify that the inspection of ..............................

was conducted by the County Health Management Team of ...................... on

.............. day of ................ 20 ......... under my personal supervision.

I further certify that the inspection was witnessed by

Dr./Mr./Mrs./Miss ................................................ being the

Owner/Director/Applicant* and that .............................................

the said institution does/does not* meet the minimum requirements for Registration/Licensing purposes.

Dated this ....................... day of ....................... 20 ........................

Signature....................................

(Medical Officer of Health)

Name of Station ........................................

Address.................................................

Telephone Number ....... I .................

*Delete where inapplicable

PART VII

(To be completed by the Applicant/Director/Owner of the institution in duplicate)

I, Dr./Mr./Mrs./Miss* ..................................................

(Full Names in Block Letters)

hereby certify that all the information given by me in the application form is true and correct and that I personally witnessed the inspection which was conducted by the Medical Officer of Health on

.......................... day of ..................... 20 ...........

Signature..............................................

Name in Full .......................................

APPLICANT TO NOTE:

This form MUST be returned to the Medical Practitioners and Dentists Board within a period not exceeding three months from the date of issue. Applications which are not returned within the stipulated period shall be time barred.

PART VIII

(For the purposes of vetting applications and enforcement of Laws, Regulations and Decisions of the I.R.C. and the Board.)

(a)

Name of the institution acceptable to the IRC ....................

(b)

Type of institution ................................

(c)

Give Name, Type, Location and Registration Number of other institutions operated by operated by the Applicant/ Director or affiliated to the institution named in this application:

(i) ..............................................
(ii) .............................................
(iii) ............................................
(iv) ............................................
(Use extra space if necessary).

*Delete where inapplicable

(d)

Give full particulars of criminal court proceedings for violations of any of the following Ministry of Health laws by any of the institution named in paragraph (c) in this application (Cap. 253, Cap. 260, Cap. 257, Cap. 244, Cap. 245, Cap. 254 and Cap. 242) (Quote court case references in each case for the past three years proceeding the date of this application).

...........................................................................

(use extra space if necessary).
(e)

Give names of institutions, their location and registration numbers from among those named at paragraph (c) in this application which have defaulted in licence fees payment during the past three years. State each year of default and penalty imposed and whether or not/penalty has been paid and fees recovered:

....................................................................................

(use extra space if necessary).
(f)

Give names of any of the institutions named at paragraph (c) in this application which the Board has authorized closure during the past three years (quote minutes references of the I.R.C. and state the institutions' registration number and place of location).

........................................................................................

(Use extra space if necessary).
(g)

F.R.L. Serial No. and date of this application ..................................

(h)

Licence Fees Category (quote I.R.C. minutes reference) .......................

(i)

F.R.L. Receipt No. and Date ................................................

(j)

Date application returned to applicant ............................................

(k)

Date application re-submitted by applicant .....................................

(l)

Registration Fees Receipt No. and Date ...........................................

CERTIFICATE BY AN OFFICER AUTHORIZED FOR THE PURPOSES OF PART VIII OF THIS APPLICATION
(This certificate must be countersigned by the Registrar)

I certify that the institution for which this application is made and its Owner/Director/Applicant or its Administrator has/has not been* subject to the criminal proceedings in violation of any of the laws named in Paragraph (d) in this application and that all information given under PART VIII of this application is correct and true.

Dated this ................... day of .................... 20 .............

...........................................................Authorized Officer

Registrar, Medical Practitioners and Dentists Board

PART IX

FOR OFFICIAL USE ONLY
1.

INSTITUTION REGISTRATION COMMITTEE'S RECOMMENDATIONS

............................................................................

..............................................................................

Dated this ............ day of ........................ 20 ........

Chairman Medical Practitioners and Dentists Board

Chairman, Committee

*Delete where inapplicable

2.

INSTRUCTIONS TO THE REGISTRAR BY THE BOARD

....................................................................................................

Dated this ............... day of ........... 20 .....

.......................................................

Chairman Medical Practitioners and Dentists Board

______________________________

PART VIA

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)

APPLICATION FOR RECOGNITION OF SPECIALIST/SUB-SPECIALITY STATUS
1.

Surname .................. Other Names .................. Reg. No ...............

2.

Date of Birth ....................................... Nationality .................

3.

Address ............... Code ............... Town .................. Cell Phone ..................

Email ................................................................................

4.

Employer ........................................................

5.

Degree, Diploma or Licence held (give name of medical school and date qualified)

........................................................................

6.

Specialty/sub-speciality applied for .............................................

7.

Postgraduate qualifications: medical/dental school ...............................

Date qualified ........................................................

8.

Number of years of experience in speciality/sub-speciality after obtaining postgraduate qualifications (indicate the number of years or months, name of institution(s) attended and name of two supervisors whose address must accompany this application).

No. of Years/Months .............. Name of Institution ............ Country ................

Supervisors: (a) Name ......................... Address ................ Code ...............

Email : ...................... Telephone: .........................

(b)

Name ...................... Address ....................... Code ..................

Email: ....................... Telephone: ........................

Requirements:

(i) Copy of post graduate qualifications and official transcripts;

(ii) Evidence of completion of 2 year full time rotation in a recognized institution for specialist recognition;

(iii) Supportive recommendation from two (2) supervisors in the relevant field;

(iv) For sub-speciality recognition, the applicant should show evidence of training for at least one year;

(v) Speciality and sub-speciality must be in the gazetted list;

(vi) Application fee- KSh. 20,000.00

All payments should be made at any KCB Branch countrywide to Board's account No. 1103158643, Milimani Branch.

I hereby certify that the above information is correct to the best of my knowledge and that I have met all the above requirements.

Signature of Applicant ......................... Date ...................

FOR OFFICIAL USE:

This process takes a maximum of two (2) weeks.

PREPARED BY:-Name: .........Designation ............Signature ................ Date ..................CHECKED BYName: ......... Designation ...........Signature ............... Date ...............

APPROVED/NOT APPROVEDSpecialty/SubSpecialty.............Name .............................Designation ...........................Signature ................. Date .................

______________________________

FORM VII

(r. 8)

Licence No. ...............................

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
LICENCE FOR PRIVATE MEDICAL OR DENTAL PRACTICE
1.

Dr./Mr./Mrs./Miss* ........................................

....................................................................

(full names in BLOCK LETTERS) of ................................................

...................................................... (full address) is hereby licensed in accordance with the provisions of section 15 of the Act to engage in private practice on his/her* own behalf as a private medical/dental practitioner or to be employed whole-time/part-time*, by a private practitioner, Dr./ Mr./Mrs./Miss* ......................... (name and address of the employer private practitioner.)

2.

This licence entitles the holder to engage in General Practice/Specialist Practice* in (specify discipline).

3.

Authorized premises to be used for the purposes of private practice (detailed particulars and location of authorized premises).

4.

This licence shall expire on the last day of ..................., 20.............

5.

No change of premises is permitted without the authority of the Board.

Dated this ..................... day of ................. 20 ................

.....................Registrar of Medical Practitioners and Dentists

*Delete where not applicable.
______________________________

FORM VIII

(r. 9)

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
APPLICATION FOR RECOGNITION OF SPECIALIST/SUB-SPECIALITY STATUS
1.

Surname (BLOCK LETTERS).............................................

2.

Other names .....................................................

3.

Registration No. .............................................

4.

Address ..........................................................

5.

Place and date of birth ..................................

6.

Nationality .................................................

7.

Places of practice .........................................

8.

Degree or diploma (give name of Medical School and date qualified) .......

9.

Speciality or sub-speciality in which specialist/sub-specialist status sought (state clearly) ...

10.
(a)

Postgraduate qualifications (indicate the discipline, name of institution, country and date qualified) ...................

(b)

Duration of the course(s) .......................................

11.

Number of years of experience after obtaining postgraduate qualifications (indicate the number of years or months, name of institution(s) attended and name of supervisor, whose letter must accompany this application) ......................................................

12.

List of publications (if any) .....................................

13.

Number of years experience in sub-speciality (indicate clearly number of years or months, name of institution(s) attended and name of supervisor, whose letter must accompany this application)

14.

I solemnly and sincerely declare that the information given is true.

Dated the ......................., 20..................

Signature of applicant

______________________________

FORM IX

(r. 4(1))

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
APPLICATION FOR REGISTRATION OF A PRIVATE MEDICAL INSTITUTION

PART I

(To be completed by the applicant in triplicate)
1.

Name and Address of the Proposed Institution (Block Letters) ................................

2.

Type (State whether Hospital, Nursing Home, Maternity Home, Health Centre, Dispensary, Laboratory, etc. ..................

3.

Location of the Institution: .......................................

(a)

Town/Centre/Market* ....................

(b)

Location ..........................................

(c)

District .........................................

(d)

Province .........................................

*Delete where inapplicable

PART II

(To be completed by the applicant in triplicate)
1.

Full Name and Address of the Applicant (BLOCK LETTERS) ........................

2.

State if Applicant is a Director and/or Administrator of the Institution ......

3.

Nationality of the Applicant ..........................

4.

Place and Date of Birth .................................

5.

Kenya National Identity Card No. ........................

(Attach photocopy)

6.

Passport No. (if applicable) ...............

7.

Work Permit No. (if applicable) ..................

(Attach documentary evidence-copies only).

PART III

(To be completed by the applicant in triplicate)

Give full names of Directors of the Institution including the following: Nationalities, Passport Numbers, Work Permit Numbers, Kenya National Identity Card Numbers, etc.

(Attach copies of documentary evidence)
(a)

......................................................

(b)

.......................................................

(c)

.........................................................

(Use extra space if necessary)

PART IV

(To be completed by the applicant in triplicate)
1.

Give full names of Medical or Dental Practitioner who shall be in-charge of patient health care at the proposed institution ..................................

2.
(a)

Give full details of professional qualifications of the person named in paragraph (1) above. Include year and place where obtained.

(b)

State work experience of the person named in paragraph (1) above and name institutions where obtained and date.

(c)

Attach copies of documentary evidence in each case. (Use extra space if necessary)

3.
(a)

Give full names and professional qualifications of any other person(s), identified by your institution, to undertake patient health care at the institution (e.g. Clinical Officers, Nurses, Laboratory Technicians, X-ray staff, Doctors, Technicians, Pharmaceutical Technologies, etc.)..............................................

(b)

Attach copies of documentary evidence in each case. (Use extra space if necessary).

(i) ....................................................................
(ii) ....................................................................
(iii) ...................................................................
(iv) ....................................................................
(v) .....................................................................
(vi) ....................................................................

/PART V -

(To be completed by the Medical Officer of Health in triplicate)
INSPECTION REPORT FOR PRIVATE MEDICAL INSTITUTION FOR REGISTRATION PURPOSES
1.

Name of Institution ......................................................

2.

Physical Location:

(a)

Plot No./L/R. No. ................................

(b)

Market/Centre/Town* ..............................

(c)

Street/Road* .....................................

(d)

Division .........................................

(e)

District .........................................

(f)

Province .........................................

*Delete where inapplicable.

3.

Premises General Information:

(a)

Plot area (in hectares) ......................

(b)

Water supply .............. adequate/inadequate*

(c)

Refuse Disposal:

(i) Incenerator available/Not available *.
(ii) Other modes of refuse disposal.
(Specify)

..........................................................................................

*Delete where inapplicable.
(d)

Environmental suitability ...................... recommended/not recommended* State reasons for not recommending.

.......................................................................

.......................................................................

4.

Plan of the Institution:

(a)

Approved/Not approved* by the local District Development Committee (attach copy of the plan) and documentary evidence (copies) of approval of the institution by the D.D.C.

5.

Out-patient Services:

(See attached minimum requirements for General Practice).

(a)

Waiting Bay/Reception Area/Room:*

(i) Seating capacity ....................................
(ii) Area (in square metres) ............................
(iii) Construction ................... covered/not covered*.
(b)

Examination Rooms:..............................

(i) Number of rooms....................
(ii) State if equipment inspected meets the minimum requirements. (Attach separate signed list of equipment inspected if necessary).

.........................................

.........................................

........................................

(c)

Treatment rooms:

(i) Number of rooms ..........................................
(ii) State if equipment meets the minimum requirements.

(Attach separate signed list of equipment inspected).

6.

In-patient services:

(a)

Female Ward:

(i) Size of ward (in square metres) ..................
(ii) Number of beds ..........................
(iii) Number of toilets ......................
(iv) Number of bathrooms .....................
(v) Number of sluice rooms .....................
(b)

Male Ward:

(i) Size of ward (in square metres) ....................
(ii) Number of beds ......................
(iii) Number of toilets ......................
(iv) Number of bathrooms ....................
(v) Number of sluice rooms ...................
(c)

Maternity Ward:

(i) Size of Ward (in square metres) ........................
(ii) Number of beds .......................
(iii) Number of toilets ...................

*Delete where inapplicable.

(iv)

Number of bathrooms .............

(v)

Number of sluice moms .................

(d)

Paediatric Ward:

(i)

Size of Ward (in square metres) ..................

(ii)

Number of beds .....................

(iii)

Number of bathrooms.....................

(vi)

Number of sluice rooms....................

7.

Clinic Support Services:

(a)

Pharmacy:

(i) Area of waiting room (in square metres) .........................
(ii) Number of dispensing windows ..................
(iii) Number of anti-biotic (safe cupboards) ................
(iv) Number of drug stores .......................
(b)

Laboratory:

(See attached minimum requirements).

(i) Reception area (in square metres) .............................
(ii) Seating capacity.................................
(iii) Size of work-room (in square metres).......................
(iv) Equipment (Attach a separate signed list of equipment and reagents/ chemicals inspected).
(c) X-Ray Unit:

(See attached minimum requirements)

(i) Size of reception area (in square metres) .........................
(ii) Seating capacity ..........................
(iii) Number of screening rooms .........................................
(iv) Standard of radiation protection ...............................

Adequate/Not Adequate*.

(v)

Equipment (Attach separate signed list of equipment inspected).

d) Operating Theatre:

(i) Minor theatre equipment (Attach a separate signed list of equipment inspected)
(ii) Major theatre (indicate by a tick or cross in the box next to the item to show whether available or not available).

Induction room ☐

Operating room ☐

Recovery room ☐

Lighting ...................... Adequate/Not Adequate*

Equipment ............. (attach separate signed list of equipment inspected).

8.

Other Supporting Services:

(a)

Kitchen:

(i) Cooking facility (specify) .......................
(ii) Non-perishable store ................... Available/Not Available*
(iii) Perishable store ..................... Available/Not Available*
(b)

Laundry type (specify) ..........................

*Delete where inapplicable.
(c)

Mortuary:

(i) Available/Not Available*
(ii) Refrigerated/Not refrigerated*
(iii) Appropriately located/Not appropriately located*

If not appopriately located state why ..............

......................................

(iv)

Body capacity .........................

(v)

Adequate Privacy/Not Adequate Privacy* ...........

(vi)

Number of ambulances ......................

(vii)

Other facility (specify and use extra space if necessary) .......

(To be completed by the Medical Officer of Health in triplicate)
1.

Give full names and designations of members of the D.H.M.T. who participated in the inspection of the institution.

Name

Designation

(i) ....................... ........................
(ii) ....................... ........................
(iii) ....................... ........................
(iv) ....................... ........................
(v) ....................... ........................
(vi) ....................... ........................
(vii) ....................... ........................
(viii) ....................... ........................
(ix) ....................... ........................
(x) ....................... ........................
2.

Certificate by M.O.H.

I, Dr. ............................................................

State full names in Block Letters)

being the Medical Officer of Health in-charge ................ District, do hereby certify that the inspection of ......................... was conducted by the District Health Management Team of ............... on the .......... day of ......, 20....... under my personal supervision.

I further certify that the inspection was witnessed by Dr./Mr./Mrs./Miss

...........................................................................

being the Owner/Director/Applicant* and that ............................ the said institution does/does not* meet the minimum requirements for Registration/Licensing purposes.

Dated this ...................... day of ..............., 20 ..........

Signature ............................................

(Medical Officer of Health)

*Delete where inapplicable.

Name of Station .......................................

Address ...............................................

.........................................................

Telephone Number ............................

*Delete where inapplicable.
PART VII
(To be completed by the Applicant/Director/Owner of the institution in triplicate)

I. Dr./Mr/Mrs./Miss* ..........................................

(Full Names in Block Letters)

hereby certify that all information given by me in this application form is true and correct and tht I personally witnessed the inspection which was conducted by the Medical Officer of Health on the .... day of ......, 20...........

Signature .................................................

Names in Full ............................................

APPLICANT TO NOTE

This form MUST be returned to the Medical Practitioners and Dentists Board within a period not exceeding thrre months from the date of issue. Applications which are not returned within the stipulated period shall be time barred.

PART VIII

(For the purposes of vetting applications and enforcement of Laws, Regulations and Decisions of the I.R.C. and the Board)

(a)

Name of institution acceptable to the IRC. .......................

(b)

Type of institution .................................................

(c)

Give Names, Types, Locations and Registration Numbers of other institutions operated by the Applicant/Director or affiliated to the institution named in this application.

(i) ......................................................
(ii) .......................................................
(iii) ......................................................
(iv) ........................................................
(v) ........................................................ ...........................................................
(Use extra space if necessary)

*Delete where inapplicable

(d)

Give full particulars of criminal court proceedings for violations of any of the following Ministry of Health laws by any of the Institutions named in paragraph (c) in this application (Cap. 253, Cap. 260, Cap. 244, Cap. 245, Cap. 254, and Cap. 242 (Quote court case references in each case for the past three years proceeding the date of this application).

.........................................................................................

(Use extra space if necessary)
(e)

Give names of institutions, their location and registration numbers from among those named in paragraph (c) in this application which have defaulted in licence fees payment during the past three years. State each year of default and penalty imposed and whether or not/penalty has been paid and fees recovered:

...........................................................

(f)

Give names of any of the institutions named at paragraph (c) in this application which the Board has authorized closure during the past three years (quote minutes references of the I.R.C. and state the institutions' registration number and place of location).

................................................................................

(Use extra space if necessary)
(g)

F.R.L. Serial No. and date of this application ...................

(h)

Licence Fees Category (Quote I.R.C. minutes reference).............

(i)

F.R.L. Receipt No. and Date .........................................

(j)

Date application returned to applicant ..............................

(k)

Date application re-submitted by applicant .......................

(l)

Registration fees Receipt No. and Date ....................

CERTIFICATE BY AN OFFICER AUTHORIZED FOR THE PURPOSES OF PART VII OF THIS APPLICATION
(This certificate must be countersigned by the Registrar)

I, certify that the institution for which this application is made and its Owner/Director/Applicant or its Administrator has/has not been* subject to the criminal proceedings in violation of any of the laws named in Paragraph (d) in this application and that all information given under Part VIII of this application is correct and true.

Dated this ............ day of ..........., 20 ............

................................................................

Authorized Officer Registrar, M.P. and D.B../D.M.S.

*Delete where inapplicable.
FOR OFFICIAL USE ONLY

1. Institution

Registration

Committee

Recommendation

..........................

.......................

....................................

.....................

.............................

.............................

............................

...........................

..........................

....................

............................

.........................

......................

......................

...............................

.......................

Dated this ........... day of ............, 20 ...........

INSTRUCTIONS TO THE REGISTRAR BY THE BOARD

......................................................................................

................................................................................

Dated this ............ day of ........., 20 .........

........................................................

Chairperson

Medical Practitioners and Dentists Board

______________________________

FORM X

(r. 4(3))

[L.N. 26/2000, r. 2, L.N. 161/2015.]

Serial No......................

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
CERTIFICATE OF REGISTRATION AS A PRIVATE MEDICAL INSTITUTION
1.

Name of Institution .....................................

P. O. Box .............................................

2.

Type ............................................................

has been registered as a Private Medical Institution in accordance with rule 4 (3) of the Medical Practitioners and Dentists (Private Medical Institutions) Rules.

Date ...........................

SEAL OF THE BOARD

(r. 5(1))

...........................CHAIRMAN M.P. & D. BOARD

.............................REGISTRAR M.P. & BOARD/DMS

(a)

It shall be the duty of the holder of this certificate to inform the Registrar within fourteen (14) days of any change in the registered address in accordance with rule 5 of the Medical Practitioners and Dentists (Private Medical Institutions) Rules.

______________________________

FORM XI

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)

APPLICATION FOR PRE-REGISTRATION EXAMINATION
1.

Surname ................................ Other Names ........................

2.

Date of Birth ......................... Nationality ......................

3.

Address ................... Code ............... Town .................. Tel ....................

Email ............................. Mobile ..............................

4.

Degree, Diploma or Licence held (give name of medical school and date qualified — if degree not in English, provide official translation).

...............................................................

5.

Particulars of Experience (e.g. posts held, type of practice in which the applicant has been engaged, countries in which the applicant has practiced:

6.

Testimonials Covering the Period(s) of Experience

........................................

7.

Have any arrangements been made regarding employment? (if so, give details) ..................

Requirements:

(i) Copy of ID/Passport;

(ii) Coloured passport size photograph;

(iii) Certified copies of professional certificates;

(iv) Evidence of appropriate linguistic skills in English and/or Kiswahili for non-Kenyans;

(v) Academic transcripts or evidence of internship;

(vi) Curriculum Vitae;

(vii) Must be attached at a training institution approved by the Board for a period of four (4) months;

(viii) Evidence of completion of internship or registration from a Medical Council;

(ix) Evidence of employment/job offer in a recognized institution;

(x) Letter from Commission for Higher Education (CHE) confirming recognition of the medical/dental school (if foreign trained);

(xi) Qualification (Form IV or VI certificates);

(xii) Application fee KSh. 5,000.00;

(xiii) Examination/evaluation of qualification papers - Fees KSh. 50,000.00.

All payments should be made at any KCB Branch countrywide to Board's account No. 1103158643, Milimani Branch.

Signature of applicant

................................. Date ..............................

FOR OFFICIAL USE:

PREPARED BY: -Name: .............Designation ......................Signature ........................ Date .............CHECKED BY:-Name: .................. Designation ................Signature ........................ Date .............

APPROVED/NOT APPROVEDName ................................................Designation ...................................Signature .........................................Date ...............................................

______________________________

___________________________

FORM XII

(r. 5(3))

Serial No............

[ L.N. 26/2000]

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
ANNUAL FEES ASSESSMENT FORM
PART A
(to be completed in triplicate)
1.

Name of Institution .................................................

2.

Registration Number and Date ....................................

3.

Physical Location ........................................

4.

Name and Address of Applicant for Licence ..................................

5.

Fees Category for Year ...................

(I)

(II)

(III)

(IV)

(V)

(tick relevant box)

6.

Fees Rates Applicable to Instution ..........................

Licence fees (amount in words) ........................................

.......................................................................

PART B
(to be completed by M.O.H. in triplicate)
CERTIFICATE BY MEDICAL OFFICER OF HEALTH

I, Dr. (Full Names in Block Letters) ...............................

Being the Medical Officer of Health in-Charge ......................

.................................................................

District of ..........................................

Province do hereby certify that the institution named in this application form was last inspected on ................. day of .............., 20 ......... and in my opinion the current condition of its premises requires/does not *require fresh inspection.

(*delete where inapplicable)

Dated this ............... day of ............, 20.........

OFFICIAL SEAL

..................................Medical Officer Of Health

STATION............

ADDRESS...............

TELEPHONE..........

(a)

Plot No. .......................................

(b)

Town/Market* ..................................

(c)

Street/Road* ...................................

(d)

Location ......................................

(e)

Division ......................................

(f)

District ..........................................

(g)

Province ..........................................

7.

Date of last inspection of the Institution by the Ministry of Health

............................................................................................

*Delete where inapplicable.
PART C
(to be completed by the applicant in triplicate)
CERTIFICATE BY THE APPLICANT

I. Dr./Mr./Mrs./Miss (Full Names in Block Letters)................

....................................

of P.O. Box ...............................

being the Administrator/Owner/Director* (Specify other) .............

.......................................................................

of (give full names of the institution) ..................................

..........................................................................

do hereby certify that the information given by me in this application is true and correct.

Dated this ............ day of ..............., 20 ........

........................................Applicant

PART D
(FOR OFFICIAL USE ONLY)
(a)

Acceptable name of institution and type ...............

...................... ...............................

(b)

FRL Serial Number and Date ..................................................

(c)

Registration Certificate Number and Date .................................

(d)

Licence Fees Assessment Number and Date .........................

(e)

Category of Licensing ...............................................

(f)

Registration Fees Receipt Number and Date .............................

(g)

Date application sent to IRC/Board ..........................................

(h)

Remarks ................................................................

I certify that I have personally checked the information above and found it correct and that all procedures and documentation pertaining to this application have been complied with.

Dated this ............... day of ............, 20 ..........

.....................Registrar M.P. & D.B/Director of Medical Services

___________________

FORM XIII

(r. 5(4))

Serial No............

[L.N. 26/2000, r. 2.]

THE MEDICAL PRACTITIONERS AND DENTISTS ACT
(Cap. 253)
LICENCE TO OPERATE A PRIVATE MEDICAL INSTITUTION

LICENCE NO...............

1.

Name of Institution ........................................

(Full Names in Block Letters)

of P. O. Box ................................

(full address) is hereby licensed to operate a Private Medical Institution in accordance with the provisions of rule 5 (4) of the Medical Practitioners and Dentists (Private Medical Institutions) Rules.

2.

This licence entitles the Private Medical Institution to operate as ..................................

3.

Authorized Premises for the Institution ...................................

4.

Maximum Number of Patients ...................................

5.

This Licence shall expire on the last day of ............, 20..........

6.

No change of premises is permitted without the authority of the Board.

Dated this ............. day of .............., 20........

...................Registrar

MEDICAL PRACTITIONERS AND DENTISTS BOARD/DIRECTOR OF MEDICAL SERVICES
CONDITIONS OF LICENCE

This licence issued on condition that minimum requirements set by the Board for operation of the Private Medical Institutions are adhered to at all times.

_______________________

FORM XIV

[ L.N. 75/2012, r. 3]

CHECK LIST FOR SINGULAR/JOINT INSPECTIONS FOR PRIVATE OUTPATIENT MEDICAL INSTITUTIONS BY HEALTH REGULATORY BODIES IN THE MINISTRIESRESPONSIBLE FOR HEALTH

MEDICAL/DENTAL CLINIC/LABORATORY/PHARMACY/RADIOLOGY/X-RAY UNIT/MORTUARY

Date:

Basic information

I.

Name facility

2.

Address

(a) Physical

Building

County

Ward rrown/ Street

LR No.

Tel No./Mobile

Email

(b) Postal

Code

3.(a)

Proprietor

Name:

Profession:

Pin No:

(b)

Registeredowner

(a) Name

(b) Licence Certificate No.

Date of issue

Expiry date

4.

Officer in charge

(a) Qualification

(b) Registration No.

Practice licence number

5.

Name of MedicalPersonnel

Cadre

Licence Number

Date of issue

Expiry date

6.

Services offered

7.

Security ofpremises (external security & security features)(permanentperimeter fence/fire assembly points/security guard)

8.

General cleaniliness of premises

Total

10

9.

A. Medical/Dental Clinic Max score

Awarded

Comments

1. Consultation - Examination rooms

1.

Examination Equipment

4

2.

Resuscitation tray

3

3.

Infection prevention &control

3

4.

Policy, guidelines & SOPs

3

5.

Medical records

4

6.

Data Security

4

7.

HMIS/EMR

4

8.

Reports

3

9.

Ventilation

2

10.

Licences

10

Total

40

B. Pharmacy/ Chemist

Max score

Awarded

l.

Security for medications (e.g. Secure cupboards for restricted drugs, only accessible by authorizedpersons & disposal of expired drugs)

10

2.

Storage of drugs/display /labelling/ packaging conditions

7

3.

Record-keeping and documentation (Prescriptions written & received andfiled/medication errors documented and reported)

10

4.

Reference materials, Policy and SOPs as per national guidelines

3

5.

Licences

10

Total

40

C. Laboratory

Max score

Awarded

Comments

1.

Class of the licence (A-E)

4

2.

Policies, guidelines and SOPs (Including reporting procedures, handling/labelling/storage/disposal of specimens and safety program)

3

3.

Equipment management program (manuals, inventory, service contract, calibration)

6

4.

Record-keeping & Quality control of tests (EQA, IQA, control of analytical errors)

10

5.

Infection prevention and control

2

6.

Registration, storage of equipment and reagents (is there a temperature recording system)

5

7.

Licences

10

Total

40

D. Radiology/Imaging services

Max score

Awarded

Comments

1.

Current annual premise & device licence

4

2.

Policies and SOPS (Code of practice including reporting, testing, calibrating, monitoring and control)

3

3.

Quality assurance program (safety of the patient, worker, environment, security, filmstorage, quality and documentation)

10

4.

Personal radiation monitoring (Badges, dose reports)

10

5.

Radioactivewaste management programs

3

Total

30

E. Nutrition

1.

Basic Nutritionequipment and materials (weighing Stadiometer, MUAC, BP machine Blood sugar machinereferrence charts)

10

2.

SOPs (Nutritionassessment, Nutrition suppliments)

3

3.

Nutrition careprocess, nutrition assessment, Diagnosis, intervention, M&E)

7

4.

Record keepingand documentation

10

5.

Licences

10

Total

40

10.

Findings and Recommendations

11.

REGISTERED OWNER/ OFFICER IN - CHARGE

Name:................... Designation:................................ Email...................Tel No................................ Date................................. Signature ...................................

INSPECTION TEAM

Name:

Board/Council/MOH

Designation

Sign

Date

1.

2.

Name:

Board/Council/MOH

Designation

Sign

Date

3.

4.

5.

6.

FORM XV

CHECK LIST FOR SINGULAR/JOINT INSPECTIONS FOR PRIVATE INPATIENT MEDICAL INSTITUTIONS BY HEALTH REGULATORY BODIES IN THE MINISTRIES RESPONSIBLE FOR HEALTH

Basic information

1.

Name facility

N/A

2.

Category of Facility

Level

NA (to be graded atthe time of registration

3.

Proprietor owner

N/A

(a) Organization

Private ( ), Faith based ( ),GOK ( ), Community based ( ).

N/A

(b) Proprietor'sname

N/A

Current LicenceNo.

(III) Expiry date of the current licence

5

Not matching

1

matching

5

4.

Name of Officer in charge.

Current practicing licence No.

N/A

N/A

N/A

5.

Address

Physical

County

N/A

Building, Plot No.

Town, Street

Tel No.

Email

N/A

Postal

BoxNo. Code:

N/A

6.

Medical Personnel

N/A (to be graded atthe time of registration.

Name ofMedical Personnel

Cadre

Licence Number

Date of issue

Expiry date

Total numberof staff

7.

Servicesoffered

Outpatient Services YIN

MCH ( ) & HCT ( )

N/A

InpatientServices

YES/NO //(tick/circle)//

Numberof beds

Numberof cots

N/A

8.

Health Facility Infrastructure

Score

A. Building

Yes

No

N/A

1.

Building suitable for scope of work

2.

Signage for directions is in place and clear

B. Environmental - Infection Prevention

Yes

No

N/A

Comments

1.

Adequate waste management & disposal (according to guidelines )

2.

Personal protective equipment available (Gloves, gowns or dust coats, and safety boots for infection prevention)

C. Utilities

Yes

No

N/A

Comments

1.

Safe,clean running water available - Tap orcontainer). Sufficient water storage available

2.

Stable electrical power supply

Key: Ranking of scoresLevel 0: the desired activity is absent, or there is mostly ad hoc activity related to risk reductionLevel 1: the structure of more uniform risk-reduction activity begins to emergeLevel 2: the processes are in place for consistent and effective risk-reduction activitiesLevel 3: there are data to confirm successful risk-reduction strategies and continue improvement

9. Management & Recording

Scoring key

A. Generalmanagement

1

2

3

4

5

Comments

1.

Strategic plan with Vision/Mission/Values/Objectives identified

1. Not available2. Available but notin use3. In use, not known to all4. In use, not displayed5. Displayed, known and fully used

2.

Organization chart available

1. Approved by management2. Approved by board

3. Approved by an accredited body

3.

Service charter displayed

1. Not Displayed 2. Displayed 3. Regular performance review

4.

List of all staff working, including position and qualifications

//1. No list2. List available3. List with qualifications available4. List with qualifications and Job description5. Staff developmentplan available//

B. Quality Management

Comments

1.

Certifications/ accreditations

No scoring (Yes or No)

2.

Performance indicators monitored

//1. Performanceindicators (PI) not collected2. Pls collectedroutinely3. Pls analyzed4. There's feedback5. External publications//

3.

Patients charter

//1. Notavailable//2. Available 3. Displayed

4.

Feedback mechanism in place

//1. No policy2. Policy available3. Collection Mechanism available4. Regular analysis of complaints & compliments5. Evidence of action//

C. Medical Records & Information Systems

Comments

1.

2.

Medical records for each patient (files - manual/ electronic)

//1. No medical records2. Separate medicalrecord for each patient3. All patients are triaged//

//4. Comprehensivemedical notes5. Notes are legible and signed//

3.

Approved register is kept of all patients (An outpatient and inpatient register)

//1. Noregisters2. Old registers3. Current registers available4. Registers correctlyused//

4.

Records are kept in a secure place

//1. No restrictedaccess to files2. There's restricted access to files3. Files kept in lockable cabinets and onlyauthorised personscan access//

5.

Contributes to external databases and reports, periodically (Linkage to national HMIS)

//1. No routine reports2. Routine reports available butnot reported3. Routine reports submitted irregularly4. Routine reportssubmitted regularly//

D. Equipment Management

Comments

1.

Preventive maintenance plan for equipment

//1. No preventive plan 2. Service contract available3. Equipment checked on schedule and results documented4. Due date for next maintenance documented//

2.

Calibration

//1. Machines not calibrated2. No contract for calibration3. Calibration not regular but contract available4. Calibration regular with results available//

10.

Patient Services

Scoring system

Comments

A. Consultation

1.

Consultation - Examination rooms

1. Examination coach2. The above withscreen3. The abovewith steps4. The above withmackintosh5. All theabove with bed sheet

2.

Sink/wash basin

1. Sink available2. The above withSink withoutrunning water3. The above withSink with running water from the tap4. The above with Sink with all ofthe above with soap5. All the abovewith Sink withrunning waterand drier

3.

Examination Equipment

• thermometer• stethoscope• BP machine• weighing machine• Diagnostic kit

B. Emergency/Resuscitation room

1.

Triage

1. triage area2. Nurse not trained in triage3. Nurse trained intriage4. SoPs of triageavailable5. Proper coding of client

2.

Emergency tray

• Incompleteemergency tray• Presenceof emergency tray with all requirements

• The racks clearly labelled• All the above at designated sites• All the above and up to date list of all requirements

3.

Equipment

• Ambu bag/masks• Suction machine• Oxygen cylinder and flowmeter• Endotracheal tubes• All the above with an ideal adjustable bed

C. Sterilization Process

1.

Central Supply Unit

1. Separation areas for cleaning2. Decontamination3. Sterilization Process - SoPs available4. Storage of sterile supplies5. All the above labelled and stored in designated area

2.

Autoclave Machine

• Autoclave manual available• Autoclave electric available• SoPs available• Maintenance plan• Digitalized autoclave

D. Labour Ward

1.

Procedures for obstetric emergencies

1. Procedure for obstructed labourand foetal distress

2. Procedure for Eclampsia3. Procedure for APH/PPH/HELLP4. Availability of resuscitaire5. Resuscitaire with oxygen, the suction machine, ambubags

2.

Equipments

• Delivery bed available• Sterile delivery set• Vacuum extractor• Suction machine• Maintenance plan

3.

Monitoring of Labour

• Partograph chart available• Contraction properly charted• Cervical dilatation• Colour coding• TPR/BP

4.

Access to theatre

1. Ambulance available2. General theatre available (not close to L/W)3. General theatre available (close to L/W)4. More than one theatre5. L/W fully equippedtheatre

5.

Incubator

1. Presence of incubator2. Functional incubator3. Proper temperatureregulation

4. Oxygen connection15. Maintenanceplan

6.

Hand washing facility

1. Sink2. Sink without running water3. Sink withrunning water from the tap4. Sink with all of the above with soap5. Sink with running water and drier

7.

Sluice room

1. Presence ofsluice room2. Sluicing sink3. Availability of running water4. Decontamination backets available5. SoPs

8.

Waste management

1. Available Waste bins2. coded bins with improper lining3. bins with proper coded lining4. Good segregation practice5. All of the above with SoPs

9.

State of floor

1. Cement floor2. Cement floor with drainage3. Ceramic tile floor with drainage4. Tarazo with good drainage5. A good cleaning chart

10.

Nursing Personnel

1. nurses available2. midwives available

3. midwives available but not the right ratio 1:34. Midwives available ratio of 1:25. Midwives available ratio 1:1

11.

Oxygen source

1. Oxygen cylinders available2. External oxygen piped to IJW3. Oxygen plantSOPS4. Maintenance plan

E. Clinical Wards

l.

Oversight of patients

1. Admission procedures2. Categorization3. Patients uniform4. Clinical ward round5. Handing over/ discharge reports

2.

Patient records

1. Availability2. Non -Coded filing system3. Coded filing system4. Designated andsecure storage area E-filing

3.

Monitoring equipment

1. Thermometer2. Stethoscope3. BP machine4. Weighing machine5. Diagnostic kit

4.

Resuscitation tray

1. Presence of an emergency tray2. Presence of emergency tray with the necessary contents

13. The racks clearlylabelled- All the above at designated sites- All the above plus list of updating the contents

F. Pharmacy

SCORE

COMMENTS

0

1

2

3

4

5

1.

General conditions of premises