Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

ASSESSMENT TOOL FOR LICENSING A

MEDICAL FACILITY FOR OVERSEAS WORKERS AND SEAFARERS

I. FACILITY INFORMATION

Name of Medical Facility:

Complete Address :
No. & Street Barangay

City/Municipality Province Region

Contact Number : E-mail Address
Name of Owner/Corporation :
Name of Medical Director :
Latest DOH Accreditation Number (if renewal):
Classification: Regular Medical Facility Special Medical Facility
For Seafarers
For Land-based Workers

Certification: PCAHO ISO (Specify DOH-recognized Certifying

Expiry Date: ______________ Body): __________________________
Expiry Date: _______________

II. TECHNICAL REQUIREMENTS

Instruction: In the appropriate box, place a check mark (√) if the medical facility for overseas workers and
seafarers (MFOWS) is compliant or x mark (X) if it is not compliant.

STANDARDS AND REQUIREMENTS COMPLIANT REMARKS

A. PERSONNEL
Every MFOW shall have an adequate number of qualified, trained, and competent staff to ensure
efficient and effective delivery of the clinic’s services.
ORGANIZATIONAL CHART
The organizational chart shall be clearly structured indicating the name and designation of all personnel
with corresponding picture, and reflecting lines of authority, accountability, communication, inter-
relationships, hierarchy of functions and flow of referrals.
201 Files of Personnel
Resume

Duties and Responsibilities

Notarized Contract of Employment

Certificate of Trainings

PRC ID (If applicable)

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STANDARDS AND REQUIREMENTS COMPLIANT REMARKS

Medical Director
The medical facility shall be managed and headed
by a licensed, qualified and trained physician.
Quality Management Representative
(QMR)/Quality Assurance Officer
The QMR shall oversee the entire quality
performance of the clinic.

Name of QMR: __________________________

Examining Physician

One male and one female

At least 2 years in active practice

Registered Nurse

Licensed Dentist

Registered Medical Technologist

HIV Proficient

Registered Psychologist

Registered Psychometrician

X-ray Technologist
Optometrist (for facilities with more than 50
applicants per day)
Receptionist/clerk

Cashier

Retainer Specialist
One Pathologist
One Radiologist
Affiliated Specialists
Cardiologist

Endocrinologist

Gastroenterologist

General Surgeon
Hematologist (in areas where they are present)
Infectious Disease Specialist
Nephrologist
Ophthalmologist
Otorhinolaryngologist

Urologist

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STANDARDS AND REQUIREMENTS COMPLIANT REMARKS
Continuing program on staff development and
training
Proof of training through relevant certificates,
memos, written reports, budgetary allocation, etc.
B. PHYSICAL FACILITIES
The medical facility has adequate space for conduct of its activities.
Approved Permit to Construct
Approved Floor Plan
Business Permit
Adequately ventilated, well-lighted, clean, safe,
and functional based on the services it provides.
Program for the proper maintenance and
monitoring of physical plant and facilities
Program for proper disposal of waste and
hazardous infectious substances
shall conform to the standards set by the DOH
shall have documented procedures/processes
C. EQUIPMENT
There is an adequate number of operational equipment to provide the procedures within the
facility.
Audiometer (for sea-based)
Automated Hematology Analyzer
Clinical scale with height and weight measurement
Dental unit and chair with basic instruments
Digital imaging
ECG machine
EENT diagnostic set/s
Enzyme Linked Immunosorbent Assay (ELISA)
machine
Examining light/s
Examining table/s
Ishihara testing material
Jaeger’s chart
Sphygmomanometer/s
Psychological Test Materials (Specify the battery
of psychological tests being utilized)
Snellen’s Chart
Stethoscope/s
Urine Strip Reader (at least 10 parameters)
Program for calibration, preventive maintenance,
and repair for the equipment
Record of schedule of calibration and
maintenance of equipment
Record of reports of preventive maintenance
and repair
Documented contingency plan in case of
equipment breakdown

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STANDARDS AND REQUIREMENTS COMPLIANT REMARKS

D. STANDARD OPERATING PROCEDURES

The clinic shall have a Manual of Operations containing documented policies, protocols,
guidelines in the operation, and maintenance of the medical facility.
Administrative Policies and Procedures
Policies for hiring, orientation and promotion for all
levels of personnel

Policies for discipline, suspension, demotion, and

termination of all personnel at all levels

Policies and procedures in the maintenance of the

medical facility

Policies and procedures on Point of Care Testing

(if hospital- based)

Technical Procedures
There shall be technical procedures for the
services provided in each section of the medical
facility.

Complete history taking and physical

Examination
Dental examination
Visual acuity and color perception
Audiometry (for seafarers)
Electrocardiogram
Chest x-ray
Laboratory
Psychological Testing
There shall be policies and procedures for pre-
and post- HIV test counseling

There shall be policies and procedures for

referral of equivocal examinations for review by
the Adhoc Medical Arbiter Committee

Records Management
There shall be a system of communication,
reporting and recording of results of examinations.

Procedures for reporting and recording the

results of examinations following the
flow of PEME

Policies and procedures on access to and

confidentiality of applicant’s information

Procedures for the retention and disposal of

records which follows the standards
promulgated by the Department of Health

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STANDARDS AND REQUIREMENTS COMPLIANT REMARKS

E. RECORDS/FILES
The medical facility shall follow the template of
the Certificates of PEME both for Land-based
Workers and Seafarers

Monthly reports utilizing the BHFS prescribed

format on the following:
Statistical Report on PEME

Statistical Report on Selected Laboratory Tests

Annual Report on Cases of Repatration

Master Logbook duly registered and stamped by

BHFS
File of DOH audit reports

F. QUALITY IMPROVEMENT ACTIVITIES

The medical facility shall have policies and
procedures on Quality Assurance Program (QAP)
and Continuous Quality Improvement (CQI) reviewed
periodically.

Client Satisfaction Survey (e.g. comments,

feedback)
Records of complaints, adverse events

Corrective actions taken

Management meetings (with minutes of meetings)

Results/findings of quality assurance audits/

assessments

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Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Name of Health Facility :

Date of Inspection:

RECOMMENDATIONS:
A. For Licensing Process:
[ ] For issuance of Certificate of Accreditation as Medical Facility for Overseas
Workers and Seafarers.

Classification:

Validity from to

[ ] Issuance depends upon compliance to the recommendations given and submission

of the following within days from the date of
inspection:

[ ] Non-Issuance: Specify reason/s.

Inspected by:

Printed Name Signature Position/Designation

Received by:
Signature
Printed Name
Position/Designation
Date -
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Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Name of Health Facility :

Date of Monitoring:

RECOMMENDATIONS:
B. For Monitoring Process:

[ ] Issuance of Notice of Violation

[ ] Non-issuance of Notice of Violation

[ ] Others (Specify)

Monitored by:

Printed Name Signature Position/Designation

Received by:

Signature
Printed Name
Position/Designation
Date

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