14 Bertram Road 						 		
Milton Park 							               Attach two certified recent 
Harare								               Passport size photographs 
								
P.O.BOX A667
									AVONDALE 
									HARARE 

MEDICAL REHABILITATION PRACTITIONERS COUNCIL
 ZIMBABWE

TELEPHONE: 04-778244							Email:mrczimbabwe@gmail.com 

Health Professions Act
Chapter 27:19
APPLICATION FOR REGISTRATION OF A HEALTH INSTITUTION – OT 
(To be completed in block letters)	

1.	DETAILS OF INSTITUTION: 

NAME OF INSTITUTION………………………………………………………………………………………………………………………………..

PHYSICAL ADDRESS………………………………………………………………………………………………………………………………………

POSTAL ADDRESS…………………………………………………………………………………………………………………………………………

TELEPHONE NUMBERS (Bus)………………………………… (Cell)………………………………………… (Home)……………………

SPECIFY NATURE OF SERVICES OFFERED/ TO BE OFFERED……………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

DATE COMMENCED /TO BE COMMENCED…………………………………………………………………………………………………..

2.	NAME AND PROFESSION OF HEALTH PRACTITIONER IN CHARGE /EMPLOYED AT THE HEALTH INSTITUTION.

FULL NAMES………………………………………………………………………………………………………………………………………………..

ADDRESS……………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………

PROFESSIONAL QUALIFICATIONS………………………………………………… REGISTRATION NO ……………………………….
DATE OF QUALIFICATION………………………..DATE OF EXPIRY OF PRACTICING CERTIFICATE…………………………..

3.	TYPE OF INSTITUTION

[  ] HOSPITAL							[  ] CLINIC 
[  ] NURSING HOME 						[  ] CONSULTING ROOMS 

4.	DESIGNATION OF INSTITUTION 

[  ] GOVERNMENT 			[  ] MISSION 		[  ] PRIVATE 
[  ] LOCAL AUTHORITY 			[  ] MINES		[  ] RURAL 

5.	PROVINCE LOCATED 

[  ] BULAWAYO 				[  ] HARARE		[  ] MANICALAND 
[  ] MASH CENTRAL 			[  ] MASH EAST 		[  ] MASH WEST 
[  ] MASVINGO 				[  ] MAT NORTH 		[  ] MAT SOUTH 
[  ] MIDLANDS 			

ATTACH PROOF OF NOTIFICATION TO SET UP INSTITUTION FROM LOCAL AUTHORITY.

SPECIFY HOW YOU INTEND TO OPERATE ……………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………

6.	DETAILS OF OWNER OF PREMISES

FULL NAMES…………………………………………………………………………………………………………………………………………………

ADDRESS ……… …………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………….

TELEPHONE NUMBERS……. (Bus)…………………….……… (Mobile)………………………….. (Home)…………………………

THIS APPLICATION SHOULD BE ACCOMPANIED BY A NON- REFUNDALE FEE OF USDS$450.00 AT ZIG RBZ MID BANK RATE OF THE DAY.

I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT.

DATE……………………………………………………………..SGNATURE……………………………………………………………………………

7.  RELEVANT WORK HISTORY

Please list all work history starting with the most current position at the top. You may print and attach more pages if necessary.
FROM
(DD/MM/YY) 	TO :
(DD/MM/YY)	EMPLOYER’S NAME AND ADDRESS	JOB TITLE	BRIEF JOB DESCRIPTION	

		

		

		

8. CHECK LIST – REGISTRATION OF HEALTH INSTITUTION

Name of Institution......................................................................................................................
                              ......................................................................................................................
Physical Address.........................................................................................................................
.                           ..........................................................................................................................
Practitioner in Charge..................................................................................................................
                                  ....................................................................................................................
.                                 ......................................................................................................................  
Type of services..............................................................................................................................
Mandatory Documents to be submitted with this form
	Initial Application 	Resubmitted application 	Recommend for HPA Inspection 	Not recommended for HPA Inspection 	
MRPCZ Practitioner
 In-Charge’s current Practising Certificate 
					
Certified copies of Degrees , Diplomas, Certificates 
					
Certified copy of Identity Card
					
Practitioner’s two passport size photographs 
					
Health Inspection report from the Local Authority 

Proof of payment of application of health institution registration fee.					

9. STATUTORY DECLARATION OF EQUIPMENT
I ……………………………………………………………………………………………………………………………Full Names.
Of …………………………………………………………………………………………………………………………….. Address.
…………………………………………………………………………………………………Occupation, make the following declaration under the Health Professions Act (Chapter 27:19).
LIST THE EQUIPMENT IN YOUR PRACTICE (KINDLY TICK AND /OR ADD)
-	Plinth
-	Appropriate exercise and electrotherapy equipment for the type of treatment
- Goniometer
- Dynamometer
- Sensation testing kit
- Tape measure (3m)
- Pinch gauge
- Visual perceptual assessment kit
- Hand function test kit
- Motor proficiency test kit
- Cognitive assessment kit
• Activity based treatment equipment (at least five of the following):
- Shoulder wheel
- FEPS machine
- Sander and stand
- Skate board
- OB help arm
- Therapeutic balls (minimum set of 3 di_erent sizes)
- Pulley system
- Sensory re-education kit
- Board game
- Hand exercising activities e.g. therapeutic putty, digiflex set, power web set, etc.
• A variety of toys for different children needs
• Foot operated receptacle with self-closing devices, with plastic lining for ease of
cleaning and infection control purposes

………………………………………………………………………………………………
………………………………………………………………………………………………
 ……………………………………………………………………………………………..
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under the Health Professions Act (Chapter 27:19) and I believe that the statements in this declaration are true in every particular.
………………………………………………         				………………………………………………..
Applicant								Witness

10. REGISTRATION OF HEALTH INSTITUTIONS 
SECTION 97 OF THE ACT 

Acknowledgement of receipt of application for the registration of a Health Institution.  
Name of Applicant..........................................................................................................................................

Name of Institution.......................................................................................................................................

Address of Institution..................................................................................................................................

Fee received $.......................................				Receipt No............................................

Date............................................

In term of Section 103 of the Health Professions Act (Chapter 27:19) the Secretary General of the Health Professions Authority is hereby authorized by copy of this letter and details of your application to process the registration of your institution. 

Please note that it is illegal in terms of Section 99 of the said Act to operate a health institution without a registration certificate from the Health Professions Authority. 

D.CHIDAVAENZI
REGISTRAR 

FOR OFFICE USE ONLY

RECEIVED (Amount) …………………………………………..RECEIPT NO………………………………..DATE…………………………

APPROVED [  ] 					[  ] NO 

IF YES: DATE OF REGISTRATION ………………………………………………………….REGISTRATION NO…………………………

CONDITIONS………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………..

IF NO REASON…………………………………………………………………………………………………………………………………………….

NAME OF APPROVING OFFICER…………………………………………………………………………………………………………………..