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医保
2015/7/21 17:05:00 
遂宁本地的可以!...
2015/7/21 17:32:35 
 
护士延续注册申请审核表
来源: 作者: 发表日期:2015/7/21 17:51:13 访问次数:0
 

附件2

申请审核表

联系电话:                          

中华人民共和国卫生部制
填 表 说 明

1.本表供申请护士延续注册使用。

2.用钢笔或者签字笔填写,内容真实,字迹清晰。

3.本表的第123项由申请人填写,第4项由有关医疗卫生机构填写,第5项由注册机关填写。

4.表内的年月日时间,用公历阿拉伯数字填写。

5.申请人学历,填写护理或者助产专业最高学历。

6.申请人健康状况,填写健康状况良好、一般或者有慢性病。

7.申请人工作类别,填写临床护理、护理行政管理、预防保健或者

其他。

8.申请人现技术职称,填写护士、护师、主管护师、副主任护师、

主任护师、未评定

9.使用的照片为近期二寸免冠正面半身照。

延续注册提交的材料:

1、身份证原件及复印件一份;

2、护士执业证原件(另交复印件一份);

3、护士延续注册申请审核表一份;

4、半年内二级以上医院护士健康体检表一份;

5、延续注册所在机构《医疗机构执业许可证》复印件一份。

6、委托办理的委托书(单位加章)及受委托人身份证原件及复印件;


护士延续注册申请审核表


填报日期:                

1.申请人情况

   

   

   

出生日期

                

   

身份证号

毕业学校

所学专业

   

   

   

健康状况

毕业时间

                

护士执业证书编号

专业学习经历

2.申请人工作单位及工作详情

工作单位名称

单位登记号

行政区划

(自治区/直辖市)             地区()            县(区)

邮政编码

单位电话

工作科室

技术职称

工作类别

职务

参加工作时间

                 

3.申请人签名                                           

     

4.申请人工作单位意见(由工作单位填写)

工作单位意见:        

同意         不同意

                                                    

单位法定代表(授权者)签字

                                             

单位盖章 

                                      填写日期                 

5.注册机关意见(由注册机关填写)

准予延续注册                  不准予延续注册

不准予延续注册理由:

注册机关盖章

                                       填写日期                  

6.备注

领证人签字:

            

护士注册健康检查表

指定体检医院名称:                                体检日期:          

   

性别

出生日期

体检单位骑缝章

工作单位

民族

既往病史

甲状腺

脊柱

医师签字:

 

四肢

 

关节

泌尿生殖器

 

 

医师签字:

神经及精神

肺及呼吸道

心脏及血管

腹部器官

   

胸部X线透视

医师签字:

   

医师签字:

   

乙肝表面抗原

化验员签字:

矫正

视力

其它

眼疾

医师签字:

鼻及鼻窦

   

   

   

(以下部分请在符合项目上用“”表示:

结果:    1、健康或良好    2、一般或较弱    3、有慢性病

(如有慢性病请继续在下列符合的项目上用“”表示:

1、心血管病          6、结核病

2、脑血管病          7、糖尿病

3、慢性呼吸系统病    8、神经或精神疾病

4、慢性消化系统病    9、其它慢性病(具体):

5、慢性肾炎                                      体检医院盖章

主检医师签字:                         填写日期:              

注册机关意见

注册机关盖章

填报日期:               

注:1、表中内容请体检单位如实工整填写,不得涂改,不得弄虚作假。

2、体检后此表交注册机关。

3X线、心电图、肝功报告单请贴在背面。

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