NSQHS

1. Contact details

Are you an existing QIP client? If so, please provide your QIP Client ID.

Healthcare service name (Required)

Preferred accreditation contact name (Required)

First

Last

Preferred accreditation contact phone (Required)

Preferred accreditation contact email (Required)

Alternate accreditation contact name (Required)

First

Last

Alternate accreditation contact phone (Required)

Alternate accreditation contact email (Required)

Website

Business and/or trading name (Required)

ABN (Required)

ACN

Street Address (Required) Street Address Address Line 2

Suburb

State

Postcode

Country

Does the healthcare service have a different postal address to the street address listed above? (Required)

Yes – different postal address No – same as street address

2. Service details

Health service facility sector (Required)

Public Private

Service stream (Select all that apply) (Required)

Children’s health Community health Correctional services Dental services Mental health Rehabilitation Acute Drug and alcohol Service stream other

Governance (Required)

Public Private NGO Other

Is this organisation part of a corporate entity? (Required)

Yes No

Is this organisation currently accredited? (Required)

Yes No

Current accreditation expiry date (Required)

Would you like to provide any other information about your current accreditation and expiry dates?

3. Scope of service provision

Do any of the following accreditation frameworks apply to your health service organisation? (Select all that apply)

MPS Aged Care Module / Integrated Health and Aged Care Services Module National Safety and Quality Primary and Community Healthcare Standards National Safety and Quality Cosmetic Surgery Standards The National Clinical Trials Governance Framework Other

4. Site details

How many sites are you registering to be included in scope for the NSQHS Standards Assessment and Accreditation (this includes Administration offices)? (Required)

5. Additional information

Any additional information about your operations and/or service provision which may assist QIP with the preparation of your accreditation quote?

If applicable, are you aware of additional support services that may be required?

6. Authorisation

I declare that I am authorised to submit this scope of service on behalf of the service outlined in this form and that the information provided in this scope of service form accurately describes the organisation’s service provision. (Required)

Yes

I consent to disclosure of information relating to health service organisations to the Commission (Required)

Yes

Name of authorised representative (Required)

Position (Required)