PROVIDER ACCREDITATION-APPROVAL SELF EVALUATION STANDARD FORM Biographical Information # complete all fields This section outlines the Provider’s biographical information for record purposes. Please Name of Provider Physical Address Postal Address KwaZulu Location of Provider: Province and Natal R U R U R U R U R U R U R U R U R U Rural (R) or Urban (U) area Full Not yet Provisional Programme Present Accreditation or Programme Accreditation Accredited Accreditation Approval Status Approval status (Please tick relevant Status Status block) Name of Applicable SETA/ETQA and Accreditation or Approval Number Date of Expiry of Accreditation or Programme Approval Date of Report Contact Person(s) Provider’s Role in organisation Cell Phone: Cell Phone: Contact numbers: Office Phone: Office Phone: Fax number: Fax number: E-mail address Name of person completing the report Role in organisation Contact numbers:
PROVIDER ACCREDITATION-APPROVAL SELF EVALUATION STANDARD FORM # Biographical Information This section outlines the Provider’s biographical information for record purposes. Please complete all fields Name of Provider Physical Address Postal Address Location of Provider: Province and Rural (R) or Urban (U) area KwaZulu Natal R U R U R U R U R U R U R U R U R U Present Accreditation or Programme Approval status (Please tick relevant block) Not yet Accredited Provisional Accreditation Status Full Accreditation Status Programme Approval Status Name of Applicable SETA/ETQA and Accreditation or Approval Number Date of Expiry of Accreditation or Programme Approval Date of Report Provider’s Contact Person(s) Role in organisation Contact numbers: Cell Phone: Office Phone: Fax number: Cell Phone: Office Phone: Fax number: E-mail address Name of person completing the report Role in organisation Contact numbers:
PROVIDER%20ACCREDITATION-APPROVAL%20SELF%20EVALUATION.docx