GambarberuniformjururawatI/C saiz

JADUAL KEDUAPERATURAN-PERATURAN PENDAFTARAN JURURAWAT 1985

( PERATURAN 6 )

BORANG A

PERMOHONAN BAGI PENDAFTARAN SEBAGAI

JURURAWAT BERDAFTAR( Sila Guna Pen Hilam )

No Daftar .

Tarikh Daftar: .( Untuk kegunaan LJM sahaja )

1. Nama Pemohon dalam HURUF BESAR (seperti dalam KPITenteral Pasport)

2. *No. KP/ Tentera / Pasport: .Taraf Warganegara: .

3. Jantina: Tarikh Lahir : Tempat Lahir: .

4. Umur: Bangsa: Agama : .

5. *Taraf Perkahwinan: Bujang / Kahwin / Janda / Duda

6. a) Alamat Rumah (Tetap): .

b) No.Telefon Rumah : No.Telefon Bimbit

7. Butir-butir Kelayakan:

a) Tempat Latihan ( Nama Kolej ): .

b) Alamat Kolej : .

c) Tarikh Latihan : Dari (dd/mm/yy) hingga............................. (dd/mm/yy)

D Calon Baru D Calon Ulangan kali : .

D Calon Peralihan * No Daftar PJ / JM : (wajib tulis )

d) Tajaan : .

e) Tarikh Peperiksaan LJM :................................. (dd/mm/yy)

**Saya telah menduduki peperiksaan LJM ini kali ke: *Pertama / Ulangan : 1 / 2/ 3

8. Sesalinan dokumen -dokumen yang telah disahkan seperti di bawah:

a) Surat Beranak.

b) Kad Pengenalan lTentera / Pasport.

c) Sijil Pelajaran Malaysia / Kelulusan yang setaraf dengannya.

d) Transkrip Latihan Jururawat

* Potong Yang Mana TIDAK Berkenaan.

Borang A

9. Bayaran Pendaftaran sebanyak RM25.00 seorang dan dihantar secara kolektif melalui

kolej dengan Kiriman Wang Pos / Bank Drat kepada Setiausaha Lembaga Jururawat

Malaysia.*Perhatian:Calon hendaklah tuntut Sijil Pendaftaran ( Perakuan A ) melalui kolej masing-masing.

10. Bagi Warganegara Malaysia yang LULUS Latihan Kejururawatan di Luar Negara, bayaran

pendaftaran RM 25.00 akan diminta selepas permohonan telah diluluskan oleh Lembaga

Jururawat Malaysia. ( Kiriman Wang Pos/ Bank Drat dalam Mata Wang Malaysia)

PENGAKUAN

Saya (nama pemohon) .

dengan ini mengaku bahawa butir-butir yang dinyatakan dalam borang permohonan ini adalah

benar dan dokumen-dokumen yang dilampirkan adalah dokumen sah bagi diri saya.

Saya tidak pernah melakukan sebarang kesalahan termasuk penipuan, keburukan akhlak atau

melibatkan diri dalam kes polis. Sekiranya saya memberi maklumat palsu, saya akan dikenakan

tindakan undang-undang.

Tarikh: .Tandatangan Pemohon

PERAKUAN PENGENALAN

Saya (nama penuh) .

No Kad Pengenalan Baru .

Jawatan (tarat protesional) .

Adalah dengan ini memperakui bahawa (nama pemohon) .

yang memohon pendaftaran sebagai JURURAWAT BERDAFTAR telah mengemukakan

dokumen yang sah dan pemohon adalah orang yang sebenarnya dalam permohonan ini.

Tarikh: .

(Cop Rasmi )

Tandatangan Jururawat Berdaftar/Pengamal Perubatan Berdaftar/Peguambela / Peguamcara/Pegawai Kerajaan dalamKumpulan Pengurusan Iktisas

tlorang A 2

APPENDIX B

NURSING BOARD MALAYSIAMINISTRY OF HEALTH MALAYSIALEVEL 3, BLOCK E1, PARCEL E, PRECINCT 1FEDERAL GOVERNMENT ADMINISTRATIVE CENTRE62590 PUT RAJA YA

Tel: 603-88906023Fax: 603-88831329

Dear Sir/Madam

RE : VERIFICATION OF TRAINING

Attached herewith is the Verification of Training Form for you to forward to the College/School of Nursing / Training Hospital where you were trained.

2. Kindly advise the College / School of Nursing / Training Hospital to return the completedform DIRECT to the Secretary, Nursing Board Malaysia, at the address as above.

Thank you.

SecretaryNursing Board MalaysiaMinistry of Health

APPENDIX B

NURSING BOARD MALAYSIA

VERIFICATION OF TRAINING IN RESPECT OF APPLICATION FOR REGISTRATION

Name Address

School of Nursing: .

Date of Entry to Training: .

Date of Completion of Training:

General Education (Institution)

Malaysian Certificate of Education

Higher Certificate of Education:

Passed Nurses Final Examination Date:

Nursing Board I Council with which applicant is currently registered.

THEORY Summary of THEORY Summary of

Total Theory Hours Total Theory HoursHealth Sciences Nursing Patients with altered:- Anatomy & Physiology - Respiratory System- Biochemistry - Haemopoietic System- Microbiology - Alimentary System- Environmental Health - Cardiovascular System- Parasitology - Reproductive System- Epidemiology - Musculoskeletal System- Pharmacology - Endocrine System- Nutrition - Genitourinary System

Anaesthesia - Communicable InfectionsBehavioural Sciences - Nervous System- Psyhology - Dermatologi- Sociology - Eye- Communication - Ear, Nose & Throat- Human & Public Relations - Psychiatric

Nursing Sciences - Obstetric Nursing- Principles & Practice of Nursing - Gerontological Nursing- Professional Development - Emergency Care- Medical-Legal Aspects of Nursing - Management- Community Health Nursing - Health System Research

Civics - PaediatricFluids & Electrolytes Imbalance

Burns & Scalds

Infection & Inflammatory Conditions Total

PRATICUM Skills Laboratory Clinical Experience

(Week) (Week)

Nursing

- Medical

- Surgical

- Orthopaedic

- Paediatric

- Gynaecological

- Obstetrics

- Dermatologi

- Eye

- Ear, Nose & Throat

- Communicable

- Psychiatric

- Intensive Care

- Operation Theatre Technique

- Accident & Emergency

- Community

- Management

TotalPlease turn overleaf

CONTINUATION OF APPENDIX B-1

Year Theory Supervised Experience Clinical Vacation Sick Leave Others

(Hours Skill Laboratory Practice Leave

(Week) (Week) (Week) (Days)

Hospital Data

Total Number of Beds

Average Daily Occupancy

Average Number Of Registered Nurses

Number Of Tutors

Name of Affiliated Hospitals Total Number of Beds

Signature

Name: .

(Principal Tutor)

School Seal

Date

NURSING BOARD MALAYSIA

CONTINUATION OF APPENDIX B-2

Verification Of Post-Basic Experience

POST BASIC COURSES

Name Of Course Duration Of Course

1.

2.

3.

POST BASIC CLINICAL EXPERIENCE

Areas Of Clinical Experience Durations In Week

1.

2.

3.

4.

5.

6.

Director Of Nursing

Date:

Seal:

APPENDIX C

NURSING BOARD MALAYSIA

MINISTRY OF HEALTH MALAYSIA

LEVEL 3, BLOCK E1, PARCEL E, PRECINCT 1

FEDERAL GOVERNMENT ADMINISTRATIVE CENTRE

62590 PUTRAJAYA

Tel: 603-88906023Fax: 603-88831329

VERIFICATION OF NURSE REGISTRATION I LICENSE TO PRACTICE

Part A: To be completed by the applicant in BLOCK letter please.

Name: .Address: .

School of Nursing.... . .Date of Training: From To .Registration No. : Registration Date .

Part B : To be completed by the Nursing Board / Council and return directly to the Nursing BoardMalaysia at the above Address. This verification is acceptable only if submitted directly from the NursesRegistration Board / Registration Council to the Nursing Board Malaysia.

I confirm that the Nurse / Midwife named above has correctly recorded the details of her Registration / thisRegistration is / is not currently valid (please delete as appropriate).

The language of instruction and examination was

Type of Registration: D Registered Nurse D Midwife

Application registration by: D Exam D Endorsement

D Enrolled Nurse

Initial Registration Date in Jurisdiction

Has this person's registration / license ever been denied, revoked, suspended or under review?DYes D No

If yes, has this person's registration / license been reinstatedD Yes (date: .. )

Is there licensing for practice? D DYes

D No

D No

If yes, status of license: D Current D Inactive D Lapsed

Nama of Board / Council . .. .Address of Board / Council: .Name of officer completing verification : .Title of officer completing verification: .

Date Signature: .

Official Seal