The Medical Practitioners and Dentists (Forms and Fees) Rules

Legal Notice 19 of 1978

This is the latest version of this Legal Notice.

Citation: Legal Notice 19 of 1978
Primary work: Medical Practitioners and Dentists Act
Date: 31 December 2022
Language: English
Type: Legal Notice
Publication: Download PDF (4.1 MB)

MEDICAL PRACTITIONERS AND DENTISTS ACT

THE MEDICAL PRACTITIONERS AND DENTISTS (FORMS AND FEES) RULES

LEGAL NOTICE 19 OF 1978

Published in Kenya Gazette Vol. LXXX—No. 3 on 20 January 1978
Commenced on 1 January 1978

[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1983 (Legal Notice 76 of 1983) on 13 May 1983]
[Amended by Medical Practitioners and Dentists (Forms and Fees) Rules, 1978 Corrigenda (Corrigendum 26 of 1983) on 27 May 1983]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1988 (Legal Notice 204 of 1988) on 20 May 1988]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1995 (Legal Notice 349 of 1995) on 3 November 1995]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1997 (Legal Notice 138 of 1997) on 25 July 1997]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2000 (Legal Notice 26 of 2000) on 17 March 2000]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2005 (Legal Notice 80 of 2005) on 1 September 2005]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2010 (Legal Notice 135 of 2010) on 10 September 2010]
[Amended by Medical Practitioners and Dentists (Forms and Fees Amendment) Rules, 2012 (Legal Notice 12 of 2012) on 1 February 2012]
[Amended by Medical Practitioners and Dentists (Forms and Fees)(Amendment) Rules, 2012 (Legal Notice 75 of 2012) on 1 July 2012]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2015 (Legal Notice 161 of 2015) on 7 August 2015]
[Amended by Medical Practitioners and Dentists (Forms and Fees)(Amendment) Rules, 2017 (Legal Notice 4 of 2017) on 27 January 2017]
[Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2021 (Legal Notice 255 of 2021) on 24 December 2021]
[Revised by 24th Annual Supplement (Legal Notice 221 of 2023) on 31 December 2022]

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. 8,000.00All 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 USEThe 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. 4,000All payments should be made to:Medical Practitioners and Dentists BoardAccount No: 1103158643,Bank: KCB, Milimani Branch.SWIFT CODE: KCBLKENXBANK 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:...................................................................................................................................................................................................

(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)..................................................

(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.HI, 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 byDr./Mr./Mrs./Miss ................................................ being theOwner/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 ........

ChairmanMedical Practitioners and Dentists Board

Chairman, Committee

*Delete where inapplicable

2.INSTRUCTIONS TO THE REGISTRAR BY THE BOARD....................................................................................................Dated this ............... day of ........... 20 ............................................................

ChairmanMedical 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. 20,000.00All 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 ..................................

(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)

(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 NOTEThis 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:...........................................................

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

(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 .................................................................ChairpersonMedical 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

Servicesoffered

Outpatient Services YIN

MCH ( ) & HCT ( )

N/A

InpatientServices

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

Numberof beds

Numberof cots

N/A

Health Facility Infrastructure

Score

A. Building

Yes

N/A

Building suitable for scope of work

Signage for directions is in place and clear

B. Environmental - Infection Prevention

Yes

N/A

Comments

Adequate waste management & disposal (according to guidelines )

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

C. Utilities

Yes

N/A

Comments

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

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

Comments

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

Organization chart available

1. Approved bymanagement2. Approved by board

		3. Approved by anaccredited body
3.	Service charter displayed	1. Not Displayed2. Displayed3. 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. Available3. 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
	Adequate general condition of premises (Hygiene, sanitation, ventilation, state of repair, running water, light, adequate space, displayof drugs)
2.	Medications
	Conditions of medications adequate(e.g. security, display, labelling, expiry dates)
3.	Record Keeping/ Documentation
	Prescriptions received and recorded
	G. Medical/Dental Laboratory
1.	Licensin 2
	Licensed for services per class (C,D,E)
2.	SOPs
	Standard Operating Procedures & guidelines available (according to Class: Including reporting procedures, handling/ labelling/ storage / disposal of specimens and safety program)
3.	Quality assurance
	Quality control practiced (Equipment/reagent registered, validated, calibrated and quality control of tests, well maintained equipment, storage)
4.	Infection prevention and control
	Infection prevention and control practices observed (waste management and sharps disposal, Personal protective equipment)

	H. Radiology and ImagingServices	Scoring						Comments
		0	1	2	3	4	5
1.	Licenses
	Premises & devices
2.	Safety and storage
	Safety of personnel, environmentand patient adequate, quality assurance and equipment management (personalsafety and control area safety, waste management)
3	Documentation
	Facility Code of Practice present (including reporting, testing, calibrating, monitoring and control, standard operating procedures)
	1. Food Nutrition and Dietetics	Scoring						Comments
		0	1	2	3	4	5
1	Nutrition assessment and care plan in place for the patients
2	Availability of supplementary, therapeutic & parental feeds
3	Procurement, delivery, inspection & menu and service of food according to laid protocols/procedures
4	Food & personnel hygiene and waste disposal Registered Nutritionist &Medically examined kitchen staff.
	J. Mortuary/ funeral parlour	Scoring						Comments
		0	I	2	3	4	5
1.	SOP for receiving, identification,storage and release of bodies including solid disposal
2.	Protective gear & equipment
3.	Overall environment
	K. Occupational Therapy	Scoring						Comments
		0	1	2	3	4	5
1.	Trained personnel
2.	Basic equipment
3.	room
	L. Physiotherapy	Scoring						Comments
		0	1	2	3	4	5
1.	Trained personnel
2.	Basic equipment
3.	Workshop
4.	SOP

5.	Records
	M. Orthopaedic technology		Scoring						Comments
			0	1	2	3	4	5
1.	Trained personnel
2.	Room
3.	Specialized equipment/materials
4.	SOPs
5.	Records
	N. Orthopaedic plaster and trauma		Scoring						Comments
			0	1	2	3	4	5
1.	Trained personnel
2.	Room
3.	Specialized equipment/materials
4.	SOPs
5.	records
	O. Medical and Dental Services		Scoring						Comments
			0	1	2	3	4	5
1.	Trained personnel
2.	Basic Equipments
3.	SOPs
4.	Rooms
11.	Findings and Recommendations
12.	REGISTERED OWNER/ OFFICER IN-CHARGE
	Name:........................................Designation: ..............................Email.................Tel No.:.....................................Date.................................Sign:....................................
	INSPECTION TEAM
	Name:	Board/Council/MOH				Designation				Sign	Date
1.
2.
3.
4.
5.
6.

__________

FORM XVI

(r. 2(c))

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR PEER REVIEW

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

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

3.Address .............. Code ................. Town ................ Tel/Mobile ...........Email ...........................................

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) ofExperience ..................................................

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 and academic transcripts;(iv) Copy of current CV;(v) Evidence of postgraduate qualification(s);(vi) Certificate of status from current regulatory authority;(vii) Specialist Recognition (if any) from current medical Board;(viii) Application fees of Kshs. 5,000.00;(ix) Peer Review/evaluation fees of Kshs. 95,000.00.All payments should be made at any KCB Branch countrywide to Board's account No. 1103158643, Milimani Branch; SWIFT CODE: KCBLKENX, BANK CODE: 01175, BANK: KCBI hereby certify that the above information is correct to the best of my knowledge and I have fulfilled all the above requirements.Signature of applicant .................... Date ..............FOR OFFICIAL USE:The process takes a maximum of Thirty (30) days

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

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

FORM XVII

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

RENEWAL FORM FOR PRIVATE PRACTICE LICENCE 20.....

(All fields are mandatory)

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

2.Date of Birth ...........................

3.Address .................. Code ............. Town ............ Mobile No .....................Email......................................

4.Employer .......................................

5.Name of authorized premises .................. County ............. Sub county .............

6.Previous Private Practice Licence Number ................................

7.Notification for any changes of name, address and/or authorized premises .................................................

8.Specialist/General practice. If specialized please specify the discipline ....................Sub Specialty .............................

9.Letter of no objection from employer/Schedule of duties should be provided for Part-time practice.

10.All applications together with payments should be received by 30th September, 20 .......

11.Late payment shall attract 50% penalty.Requirements:(i) Fees:Kenyans-A fee of Shs.15,000 is payable annually for Specialist PracticeA fee of Shs.10,000 is payable annually for General PracticeA fee of Shs.10,000 is payable annuallyfor Part-time PracticeNon-Kenyans-A fee of Shs.40,000 is payable annually for Specialist PracticeA fee of Shs.30,000 is payable annually for General PracticeA fee of Shs.30,000 is payable annually for Part-time Practice

(ii)Copy of previous licence;

(iii)Acquire a minimum of 50 CPD points.

All payments should be made at any KCB Branch countrywide to Board's account No. 1103158643, Milimani Branch.Computer generated and stamped banking slip together with renewal form should be, within the first week, either emailed to or posted to the address below.Signature of applicant .................. date .................I hereby certify that the above information is correct to the best of my knowledge.FOR OFFICIAL USE:

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

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

Physical Address: MP&DB House- Woodlands Rd off Lenana RdTel: +254 20-272 8752 1+254 20 272 4994 1+254 20 271 1478Mobile: +254 720 771 4781+254 736 771478Address: P.0 Box 44839-00100, NAIROBI-KenyaEmail: info@kenyamedicalboard.orgWebsite: www.medicalboard.co.keFORM XVIII

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR TEMPORARY LICENCE FOR FOREIGN DOCTORS

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

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

3.Address ................ Code .................. Town .................. Tel ...............Email...........................................................

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

5.Name of medical/dental school ......................... Dates qualified .....................

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

7.Testimonials covering the period of experience.......................................................

8.Name of employer: ....................... address .................. Code .....................Email.................................. Tel No ..................................

9.Is this a New Application or a Renewal? ............................. If renewal, licence No .......................................Mandatory Requirements:(i) Copy of ID/Passport;(ii) Current coloured passport size photograph;(iii) Certified copies of professional certificates and transcripts;(iv) Certificate of Status;(v) Introduction letter job offer from the institution;(vi) Copy of registration certificate from respective Medical Board/Council;(vii) Copy of current/last practice licence;(viii) Copy of current CV;(ix) Licence fee Kshs.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 I have met the above requirements.Signature of applicant .................... Date .....................FOR OFFICIAL USE:The process will take a maximum of two weeks

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

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

______________FORM XIX

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

(The Medical Practitioners and Dentist Act, Cap. 253)

TEMPORARY LICENCE FOR FOREIGN DOCTORS

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

....................RegistrarMedical Practitioners and Dentists Board

CONDITIONS OF LICENCE:

1.This licence is valid for a period of 9 MONTHS from the date hereof.

2.This licence 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 XX

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR CERTIFICATE OF STATUS

SECTION A: PERSONAL DETAILS

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

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

3.Address ..................... Code ............... Town ......... Tel/Mobile ....................Email.................................................

4.Reasons for Certificate of status ...............................................................

5.Intended county of stay/study/practice ......................... Institution ..................Period..........................................

6.If certificate is for travel, when are you expected back into the country .................

SECTION B: REFEREE

I, Dr./Prof. (Names in full) .............................(indicate Full Names as they appear in the Register)Reg. No ......................... of P.O. Box ...........................Telephone (Mobile) ....................... Email ..............................Being a practitioner of good standing, I do hereby declare that I have been and I am well acquainted with the said Dr ........................................................Reg. No./Licence No .............................................................For the past ....................... years; and further declare that during this time he/she:-

(a)has been engaged in Medical/Dental practice;

(b)has conducted himself/herself well socially and in a responsible manner;

(c)character and conduct have been ............................................

(d)reasons for certificate of status .......................................

Signed..................... Date ...........................

SECTION C: REQUIREMENTS

(i)A recommendation by a registered practitioner of good status (in section B above);

(ii)Attach copy of current retention certificate/private practice licence/temporary licence for foreign practitioner;

(iii)Evidence that the practitioner is not under any investigation by the Board;

(iv)Application fee of Kshs.20,000.00.

All payments should be made at any KCB Branch countrywide to Board's account No. 1103158643, Milimani Branch; SWIFT CODE: KCBLKEAW, BANK CODE: 01175, BANK: KCBI hereby certify that the above information is correct to the best of my knowledge and that I have met all the requirements.Signature of Applicant .................... Date .................FOR OFFICIAL USE:The process takes a maximum of two (2) weeks.

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

FORM XXI

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

APPLICATION FOR ACCREDITATION AS A CPD PROVIDER

PLEASE READ THIS SECTION CAREFULLY BEFORE COMPLETING THE FORM

(a)The application form must be completed by a duly authorized person;

(b)Every application must be accompanied by:-

(i)an application fee of Ksh. 15,000.00 (non-refundable);

(ii)calendar of activities; and

(iii)names of two referees.

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

PART A: ADMINISTRATIVE INFORMATION

1. Particularsof Applicant

(a) Name of institution;

(b) Permanent Address:

(c) Physical Address:
(d) City/Town:	(e) County:
(f) Postal Address:	(g) Postal Code:
(h) Plot No.:	(i) LR No.:
(j) Telephone No:	(k) Mobile No.:
(l) Email:	(m) Website:
(n) Fax:
2. Name of Contact Person:
Landline No.:	Mobile No.:
Email:
Any other additional information:

PART B: DECLARATION BY APPLICANT

I, the undersigned confirm that all the information in this form and accompanying documentation is correct and true to the best of my knowledge. I further agree to inform the MPDB, about any changes or modifications made to the information given in the document(s) submitted.Name of Head of Institution/Department: ............................................Signature: ..........................................................................Name of CPD coordinator: ............................................................Signature: .........................................................................Date of Application: ...............................................................Official Stamp:

PART C - FOR MPDB OFFICIAL USE ONLY

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

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

FORM XXII

THE MEDICAL PRACTITIONERS AND DENTISTS BOARD

CPD ANNUAL RETENTION FORM

PART I

Name of Provider ...................................Telephone(landline) .................................Address ............................ code ..........Physical location .....................................Website ..............................................Name of Contact Person ................................Position ...............................................Telephone ............................................Email ................................................Name & Signature of applicant ..........................Date ...................................................I hereby certify that the above information is correct to the best of my knowledge.FOR OFFICIAL USE:

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

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

Physical Address: MP&DB House- Woodlands Rd off Lenana RdTel: +254 20-272 8752 1+254 20 272 4994 1+254 20 271 1478Mobile: +254 720 771478 1+254 736 771478Address: P.0 Box 44889-00100, NAIROBI-KenyaEmail: medicalboard@kenyamedicalboard.orgceo@kenyamedicalboard.orgWebsite: www.medicalboard.co.ke

PART II

1.Part I provides information and guidelines for filling this form.

2.Part II will contain details of the CPD accredited provider. A copy of the Boards certificate should be attached.

3.Part III relates to the calendar of events. Applicants are expected to provide a detailed annual calendar of events in as much as possible the format indicated. The calendar of events should be received by the Board not later than 31st December of the preceding year.

4.Part IV will contain information of the attendees. Providers are expected to keep a record of the attendees of each activity in the prescribed form. The list of attendees should be received by the Board not later than thirty days from the date on which the activity was held.

5.A fee of Kshs 40,000/= to be paid per calendar year.

6.An application for retention shall be deemed to be for the next calendar year and can only relate to future CPD activities to be conducted.

7.CPD providers who intend to charge participants a fee shall indicate the same on the retention form and shall provide all relevant details of the same.

8.CPD programs or activities must-

(a)have significant intellectual and practical content and should emphasize ethical aspects of practice;

(b)be related to or be relevant to the practice of medicine;

(c)be of relevance and benefit to medical practitioners, dental practitioners or other health professionals, or designed specifically for registered medical institutions (whether government or private);

(d)be designed with the primary objective of increasing the professional competence of the attendee; and

(e)be approved by the Board.

9.The Board's decision shall be final.FORM XXIII

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR INTERNSHIP QUALIFYING EXAMINATION/FOR FOREIGN

TRAINED DOCTORS/EAST AFRICA COMMUNITY RECIPROCAL RECOGNITION

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

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

3.Address .................. Code .............. Town ............... Tel ......................Email .............................................

4.Degree, Diploma or Licence held (give name of medical school and date qualified if degree not in English, provide official translation)Requirements:(i) Copy of ID/Passport;(ii) Coloured pass port size photograph;(iii) Certified copies of professional certificates;(iv) Curriculum Vitae;(v) Must be attached at a training institution approved by the Board for a period of four (4) Months;(vi) Qualifications (Form IV or VI Certificates);(vii) Evidence of appropriate linguistic skills in English andlor Kiswahili for non-Kenyans;(viii) Evidence of registration ftom EAC Partner States Board's and councils (for those applying for reciprocal registration);(ix) Letter from Commission for Higher Education (CHE) confirming recognition of the medical/dental school (if foreign trained);(x) Application fee Kshs. 5,000.00;(xi) Examination/Evaluation of qualification papers Kshs.30,000.00.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 I have fulfilled all the above requirements.Signature ............................. Date .............................FOR OFFICIAL USE:

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

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

SECOND SCHEDULE

FEES PAYABLE UNDER THE ACT

[L.N. 349/1995, r. 2., L.N. 13/1997, r. 2., L.N. 26/2000, r. 2, L.N. 80/2005, r. 2, L.N. 135/2010, r. 2, L.N. 12/2012, r. 2, L.N. 161/2015, r. 2, L.N. 4/2017, r. 9, L.N. 255/2021, r. 2.]

	Item	Fees(Shs.)
1.	Indexing of a medical/dental student	1,000
2.	MEDICAL/DENTAL PRACTITIONERS
	(a) Permanent Registration of a Medical/Dental practitioner	8,000
	(b) Retention of the name of a Medical/Dental practitioner in the Register	4,000
	(c) Renewal of Private Practice Licence by Citizens of Kenya
	(i) Full-time-general practice	10,000
	(ii) Full-time-Specialist practice	15,000
	(iii) Part-time-Specialist practice	10,000
	(d) Renewal of Private Practice Licence by non-Citizen
	(i) Full-time-general practice	30,000
	(ii) Full-time-Specialist practice	40,000
	(iii) Part-time-Specialist practice	30,000
	(e) Temporary licence for foreign doctor	20,000
	(f) Specialist recognition	20,000
	(g) Exam fees
	(i) Application	5,000
	(ii) Internship qualifying exam	30,000
	(iii) Assessment,for Registration exam	50,000
	(iv) Peer review	95,000
	(h) Processing additional qualifications	20,000
	(i) Certificate of status	20,000

Item		Fees (KSh.)
Institution Fees
(a) Registration of institution
Level 1
Community Health Unit
Level 2
(i) Health Clinic		10,000
(ii) Dental Community Clinic		10,000
(iii) Dispensary		5,000
(iv) Eye Clinic		10,000
(v) Home-based Care Service		10,000
(vi) Funeral Home (stand-alone)		15,000
Level 3A
Comprehensive Health Centre		15,000
Level 3B
(i) General Practice Clinic		10,000
(ii) General Dental Practice Clinic		10,000
(iii) Home-based Care Service		10,000
Level 3C
General Medical Centre		15,000
Level 4A
Primary Care Hospital		30,000
Level 4B
(i) Specialist Medical or Dental Clinic		15,000
(ii) Specialist Home-based Care Service or Hospice		15,000
(iii) Specialist Eye Clinic		15,000
Level 5A
Comprehensive Secondary Referral Hospital		30,000
Level 5B
Secondary Referral Hospital		30,000
Level 5C
Super-Specialised Medical or Dental Centre		30,000
Level 6A
National Referral and Teaching Hospital and Specialised Hospital		30,000
Level 6B
Specialised Hospital		30,000
(b) Renewal of institution annual licence
Level 1
Community Health Unit
Level 2
(i) Health Clinic		115,000
(ii) Dental Community Clinic		15,000
(iii) Dispensary		5,000
(iv) Eye Clinic		10,000
(v) Home-based Care Service		15,000
(vi) Funeral Home (Stand-alone)		20,000
Level 3A
Comprehensive Health Centre		20,000
Level 3B
(i) General Practice Clinic		15,000
(ii) General Dental Practice Clinic		15,000
(iii) Home-based Care Service		10,000
Level 3C
General Medical Centre		20,000
Level 4A
Primary Care Hospital		80,000
Level 4B
(i) Specialist medical or Dental Clinic		20,000
(ii) Specialist Home-based care Service or Hospice		20,000
(iii) Specialist Eye Clinic		20,000
Level 5A
Comprehensive Secondary Referral Hospital		200,000
Level 5B
Secondary Referral Hospital		90,000
Level 5C
Super-Specialised Medical or Dental Centre		90,000
Level 6A
National Referral and Teaching Hospital and Specialised Hospital		300,000
Level 6B
Specialised Hospital		300,000

FEES PAYABLE UNDER THE PRIVATE MEDICAL INSTITUTIONS RULES

	Category of facility	Definition	Application fees	Registration fees	Licence fees
(a)	Dispensary	A health facility devoted to treating outpatients which is not intended to be used for more than twelve hours. Licensed to a faith based organization such as a church, a mosque, etc.	1,000	5,000	5,000
(b)	Medical clinic	A private practice health facility devoted to treating outpatients which is not intended to be used for more than twelve hours.	1,000	5,000	10,000
(c)	Eye clinic	An outpatient facility run by an ophthalmologist that exclusively offers eye services.	1,000	5,000	10,000
(d)	Eye hospital	A facility that exclusively offers eye services and has outpatient facilities; admission beds; a theatre and a cataract surgeon or ophthalmologist.	1,000	10,000	30,000
(e)	Health centre	A facility which is managed by a faith based organization, community or registered organization such as a school, a company, a church or a mosque; comprised of consulting rooms, offices, treatment rooms, laboratory and minor theatre; providing health care services which includes and limited to providing basic health services minus specialized services such as x-ray, theatre etc. Services provided include; curative, inpatient, maternity, referral, ANC/FP/immunization and laboratory.	1,000	5,000	10,000
(f)	Medical centre	A consortium of facilities and practitioners offering different services in one location.	1,000	5,000	10,000
(g)	Nursing home	A residential facility for persons with chronic illness which has a theatre and a mortuary.	1,000	10,000	20,000
(h)	Maternity home	A facility for the reception of pregnant women or women immediately after childbirth and for ante natal services.	1,000	10,000	20,000
(i)	Funeral home (stand alone)	A facility where dead bodies are stored and undergo autopsy before cremation or burial. It may provide additional services including-sale of coffins; cremation; burial and transportation, etc.	1,000	10,000	20,000
(j)	Mission hospital level 3	An establishment managed by a faith based organization which has fifty to one hundred inpatient beds; an operating theatre; a mortuary;	1,000	5,000	10,000
(k)	Mission hospital level 4	An establishment managed by a faith based organization which has over one hundred inpatient beds; an operating theatre; a mortuary; a radiology unit with x-ray and resident medical practitioners or dentists.	1,000	10,000	20,000
(l)	Hospital level4	An institution which has- fifty to one hundred inpatient beds; an operating theatre; a mortuary; a radiology unit with x-ray and resident medical practitioners or dentists.	1,000	20,000	50,000
(m)	Hospital level 5	An institution which has one hundred to one hundred and fifty inpatient beds; an operating theatre; a mortuary; an intensive care unit; a radiology unit with x-ray and resident medical practitioners or dentists.	1,000	30,000	80,000
(n)	Hospital level 6	An institution which has over one hundred and fifty inpatient beds; an operating theatre; a mortuary; an intensive care unit; a radiology unit with x-ray and resident medical practitioners or dentists.	1,000	30,000	100,000
(o)	Inspection and accreditation of a medical or dental school.	An institution which intends to train medical practitioners and dental practitioners.	15,000	50,000

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History of this document

31 December 2022 this version

Revised by 24th Annual Supplement

24 December 2021

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2021

27 January 2017

Amended by Medical Practitioners and Dentists (Forms and Fees)(Amendment) Rules, 2017

07 August 2015

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2015

01 July 2012

Amended by Medical Practitioners and Dentists (Forms and Fees)(Amendment) Rules, 2012

01 February 2012

Amended by Medical Practitioners and Dentists (Forms and Fees Amendment) Rules, 2012

10 September 2010

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2010

01 September 2005

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2005

17 March 2000

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 2000

25 July 1997

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1997

03 November 1995

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1995

20 May 1988

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1988

27 May 1983

Amended by Medical Practitioners and Dentists (Forms and Fees) Rules, 1978 Corrigenda

13 May 1983

Amended by Medical Practitioners and Dentists (Forms and Fees) (Amendment) Rules, 1983

20 January 1978

Published in Kenya Gazette 3

01 January 1978

Commenced

The Medical Practitioners and Dentists (Forms and Fees) Rules

Legal Notice 19 of 1978

Related documents

LAWS OF KENYA

MEDICAL PRACTITIONERS AND DENTISTS ACT

THE MEDICAL PRACTITIONERS AND DENTISTS (FORMS AND FEES) RULES

LEGAL NOTICE 19 OF 1978

FIRST SCHEDULE

FORMS

*Delete where not applicable.

(Use extra space if necessary).

INSPECTION REPORT FOR PRIVATE MEDICAL INSTITUTIONS - FOR REGISTRATION PURPOSES

(see attached minimum requirements)

(See attached minimum requirements).

Adequate/Not Adequate.*

(If not appropriately located, state why)

*Delete where inapplicable

(Use extra space if necessary).

(use extra space if necessary).

(use extra space if necessary).

(Use extra space if necessary).

CERTIFICATE BY AN OFFICER AUTHORIZED FOR THE PURPOSES OF PART VIII OF THIS APPLICATION

(This certificate must be countersigned by the Registrar)

FOR OFFICIAL USE ONLY

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR RECOGNITION OF SPECIALIST/SUB-SPECIALITY STATUS

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

LICENCE FOR PRIVATE MEDICAL OR DENTAL PRACTICE

*Delete where not applicable.

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR RECOGNITION OF SPECIALIST/SUB-SPECIALITY STATUS

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR REGISTRATION OF A PRIVATE MEDICAL INSTITUTION

(To be completed by the applicant in triplicate)

*Delete where inapplicable

(To be completed by the applicant in triplicate)

(To be completed by the applicant in triplicate)

(Attach copies of documentary evidence)

(To be completed by the applicant in triplicate)

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

INSPECTION REPORT FOR PRIVATE MEDICAL INSTITUTION FOR REGISTRATION PURPOSES

(Specify)

*Delete where inapplicable.

*Delete where inapplicable.

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

*Delete where inapplicable.

*Delete where inapplicable.

PART VII

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

(Use extra space if necessary)

(Use extra space if necessary)

(Use extra space if necessary)

CERTIFICATE BY AN OFFICER AUTHORIZED FOR THE PURPOSES OF PART VII OF THIS APPLICATION

(This certificate must be countersigned by the Registrar)

*Delete where inapplicable.

FOR OFFICIAL USE ONLY

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

CERTIFICATE OF REGISTRATION AS A PRIVATE MEDICAL INSTITUTION

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

APPLICATION FOR PRE-REGISTRATION EXAMINATION

______________________________

THE MEDICAL PRACTITIONERS AND DENTISTS ACT

(Cap. 253)

ANNUAL FEES ASSESSMENT FORM

PART A

(to be completed in triplicate)

PART B

(to be completed by M.O.H. in triplicate)