department of health: kwazulu-natal · l kwazulu natal department of health part b new acute...

KWAZULU NATAL DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH: KWAZULU-NATAL

health Department: Health PROVINCE OF KWAZULU-NATAL

APPLICATION FOR APPROVAL TO ERECT A PRIVATE HEALTH ESTABLISHMENT IN TERMS OF REGULATIONS GOVERNING PRIVATE HOSPTIALS AND UNATTACHED

OPERATING THEATRE UNITS REGULATION 158 OF 1980

•!• New Hospital Applications please complete

Part A & B and 0

•!• New Sub Acute Applications please complete

Part A & C and 0

COMPLETED APPLICATIONS TOGETHER WITH SUPPORTIVE DOCUMENTATION MUST BE FORWARDED TO:-

THE HEAD DEPARTMENT OF HEALTH - KWAZULU NATAL

PRIVATE BAG X9051 PIETERMARITZBURG

3200

FOR A TIENTION: MRS J N Z U Z A TELEPHONE: 033

846 7524 FAX: 033 846 7122

EMAIL: pearl . kunene@kznhealth .gov .za

APPLICATION FOR APPROVAL TO ERECT A PRIVATE FACILITY 2


Application is hereby made for a license for the following private health establishment, details of

which are supplied below.

FORM 1

PART A

NEW APPLICATIONS FOR ACUTE AND NON-ACUTE PRIVATE HEALTH ESTABLISHMENTS (This section

is compulsory and must be completed by all applicants)

1. Name of proposed private health establishment

2. In which District, city or town and suburb will the private health establishment be built?

3. What are the details of the site for development? (Please note that approvals to erect a

private health establishment are site restricted and cannot be transferred between sites.)

4. Name, address and contact details of applicant

5. How many other private health establishment licenses do you hold nationally? Provide details

of other licensed establishment, such as when the license was granted and for how long, the

number of beds and theatres and location (use separate sheet is necessary)

6. Name, address and contact details of developer, if applicable

7. Registration number of company or close corporation and list of names of shareholders and

shareholding/members


L


PART B

NEW ACUTE PRIVATE HEALTH ESTABLISHMENTS (HOSPITAL)

(To be completed for an Acute Private Establishment)

8. Number of beds applied for:

Total Beds Applied for New

Medical

Surgical

Paediatric

Intensive Care

High Care

Obstetric beds

Neonatal ICU

Day Beds

Specialist - Not Obstetric (Specify)

Total

Obstetric Unit New

Preparation Rooms

First Stage Rooms

Delivery Rooms

Total

Operating Theatres New

General Surgery

Dental

Maternity

Specialist/Dedicated (Specify)

Total

Other Yes

Trauma/Outpatient Unit

Radiology

Pathology

Central Sterilising Department

Blood Transfusion Services

APPLICATION FOR APPROVAL TO ERECT A PRIVATE FACILITY

For official Use

For official Use

II

For official Use II

No For official Use

4

2.


Physiotherapy

Occupational Therapy

Medical Suites

Other (Specify)

9. What are the clinical disciplines to be practiced in the proposed establishment? (use separate

sheet if necessary).

10. State how the number of beds was determined (use separate sheet if necessary).

11. What is the extent of the present demand for the services that will be provided?

12. Provide detailed information on each service to be provided and how the demand is

calculated.

13. In what measure will the proposed establishment meet the demand for such services? (use

separate sheet if necessary).

14. Have you taken into account both existing private and public sector facilities in your

calculations and projections?

15. Provide a map indicating the catchment area as well as an indication of all other health care

establishments (public and private) in the catchment area.

16. Provide a copy of your feasibility study (compulsory).

17. Provide detailed reasons in accordance with the criteria as set out in Annexure A as to why

this proposed establishment should be approved (use separate sheet if necessary).

18. Will you provide outpatient services?

APPLICATION FOR APPROVAL TO ERECT A PRIVATE FACILITY s


19. Num ber of medical staff to be employed

MEDICAL

FULL TIME

PART TIME

20. Number of nursing staff employed

REGISTERED REGISTERED

PROFESSIONAL STUDENT

FULL TIME

PART TIME

DENTAL

ENROLLED ENROLLED

PUPIL

21. Other full-time registered staff employed. If any spec ify.

22. Other part-time registered staff employed. If any specify.

SPECIALISTS (SPECIFY AREA OF

SPECIALITY)

ENROLLED

ASSISTANT

ENROLLED

PUPIL

ASSISTANT

23. Do you intend to do nursing training in basic and post basic courses? If yes, specify .

24. Supplementary health services person nel

i. Administrative personnel -

ii. Management -

iii. General assistant/s -

iv. Maintenance staff-

25. Any other information deemed necessary for this application (Use separate sheet if necessary)


I


PART C

NEW SUB-ACUTE PRIVATE HEALTH ESTABLISHMENTS

(To be completed for non-acute health establishments)

26 . State what type of establishment is applied for (i .e. step-down, sub-acute, rehabilitation, long

term, hospice, convalescent).

27 . Do you have any managed care or similar arrangements with any health funder/ employer?

28. Number of beds applied for and the categories of services to be rendered (use separate sheet

if necessary).

29. State how the number of beds was determined (use separate sheet if necessary).

30. What is the extent of the present demand for the services that will be provided?

31. Provide detailed information on each service to be provided and how the demand is

calculated (Use separate sheet if necessary)

32. In what measure will the proposed establishment meet the demand for such services? (Use

separate sheet if necessary)

33. Have you taken into account both existing private and public sector facil ities in your

calculations and projections?

34. Provide a map indicating the catchment area as well as an indication of all other health care

establishments (public and private) in the catchment area .

3S. Provide a copy of your feasibility study (compulsory).



36. Please attache reasons for the establishment and supporting documentation to guide the

adjudication of the application in respect of Annexure A (Use separate sheet if necessary)

37. Number of medical staff to be employed

MEDICAL DENTAL

FULL TIME

PART TIME

38. Number of nursing staff employed

REGISTERED REGISTERED ENROLLED ENROLLED

PROFESSIONAL STUDENT PUPIL

FULL TIME

PART TIME

39. Other full-time registered staff employed. If any specify.

40. Other part-time registered staff employed. If any specify.

SPECIALISTS (SPECIFY AREA OF

SPECIALITY)

ENROLLED ENRO LLED

ASSISTANT PUPI L

ASS I STANT

41. Do you intend to do nursing training in basic and post basic courses? If yes, specify.

42. Supplementary health services personnel

i. Administrative personnel -

ii. Management -

iii. General assistant/s -

iv. Maintenance staff-


1:1

II II

li


43. Any other information deemed necessary for this application (Use separate sheet if necessary)

PART D

1. What is the current zoning of the chosen site as per the latest Town planning Scheme of the

chosen town or district ?

2. Have you done all necessary site investigations which may affect the site suitability - EIA

(Environmental Impact Assessment) , TIA(Traffic Impact Assessment), Heritage matters as per

National Heritage Resources Act ? If not, provide motivation.

3. Do you have an alternative site within your targeted precinct should your first priority site be

not suitable for whatever reason?

4. Have you confirmed the availability of bulk services (power, sewer, water, etc) with the Local

Municipality?

5. Provide a schedule of activities or a programme of action plan describing each activity coupled

with anticipated duration per activity.


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6. Does the developer's Professional Team (Architect, Engineers ,etc) have healthcare related

experience? Provide detailed company profiles with specific reference to healthcare projects

previously done or currently underway.

7. Is the site selected for the development capable to allow for future expansion inclusive of

parking and future specialist needs related to healthcare disciplines -Xray Casualty , Pharmacy

Bulk,Oncology etc.

8. Is the site selected allow for public transport facilities if required in the catchment area?

9. Is a helipad required or may need to be incorporated in future?

10. Is future expansion restricted in terms of catchment with regard to oversupply of services?

11. What sustainable features will be included with the development to address Green building

initiatives?



a) I declare that I understand/agree that if approval is given for this development, it may not be

further traded, sold or transferred under any circumstances.

b) 1 hereby certify that the above particulars are true and correct.

Name ____________________ ___ Signature, __________________ _

Position held __________________ _ Date ____________________ _


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