Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

APPLICATION FOR LICENSE TO OPERATE A GENERAL CLINICAL LABORATORY

Name of Laboratory : COTABATO SANITARIUM

Address of Laboratory : Brgy. Ungap
No. & Street Barangay
Sultan Kudarat, Maguindanao _________
City/ Municipality Province Region
Telephone/ Fax No. : 064-429-0082

Head of the Laboratory : SHERJAN P. KALIM, MD, DPSP

Name of Owner : IBRAHIM V. PANGATO, JR, MD, DDM, FPMSI

Contact Number : 064-429-0082

Classification According to

Ownership : [ / ] Government [ ] Private

Function : [ / ] Clinical Pathology [ ] Anatomic Pathology

Institutional Character : [ / ] Institution Based [ ] Freestanding

Service Capability : [ ] Primary [ / ] Secondary [ ] Tertiary [ ] Limited

Status of Application : [ ] Initial [ / ] Renewal

License No.: 12-0006-17-140-HI-1_
Date Issued: January 1, 2018
Expiry Date: December 31, 2018_

Checklist of Application Documents

Please tick () the appropriate boxes under column B or C. Shaded Items are not required.

A B C
Documents For Initial For Renewal
1. Notarized Application for License to Operate a Clinical Laboratory (this form) /
2. List of Personnel (attached form) /
3. Photocopies of the following:
3.1. Proof of qualification of the medical and paramedical staff /
 Valid PRC ID
 Specialty Board Certificate of the medical staff /
 Certificate of Training/ Record of Work Experience /
3.2. Proof of employment of the medical, paramedical and administrative staff /
3.3. Current Authority to Practice for government pathologists (AO No. 161 s. 2000)
4. List of Equipment/ Instrument (attached Form) /
5. Health Facility Geographic Form (Location Map) /
6. SEC/ DTI Registration (for private clinical laboratories) OR
Issuance or Board Resolution (for government clinical laboratories)
Submit
7. Quality Manual of Clinical Laboratory (to be fully implemented by January 2009)
changes only
8. Certificate of Participation in External Quality Assurance Program OR
Form-GCL-LTO-A
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 Acknowledgement

REPUBLIC OF THE PHILIPPINES )

CITY/ MUNICIPALITY OF _______________) S.S.

I, IBRAHIM V. PANGATO, JR, Married, of legal age, 48, a resident

Name Civil Status Age
of 214A, Penaprancia Village, RH II, Cotabato City, after having been sworn in accordance with law hereby depose and say
Address
that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the attached

documents required for the Licensure and Regulation of Clinical Laboratories in the Philippines pursuant to Administrative

Order No. 2007-0027 “Revised Rules and Regulations Governing the Licensure and Regulation of Clinical Laboratories in

the Philippines”.

_________________________
Signature

Before me, this _________day of ______________ 20 in the City/ Municipality of ________________,

Philippines, personally appeared

Owner Community Tax Number Issued at/ on

IBRAHIM V. PANGATO, JR 11298058 Cotabato City/ 01-31-2018

known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is

their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2018.

Doc. No.______________________ NOTARY PUBLIC

Page No.______________________ My Commission Expires
Book No.______________________ Dec. 31, _______
Series of ______________________
Form-GCL-LTO-A
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 APPLICATION AS HEAD OF CLINICAL LABORATORY

The Director
DOH-Regional Office
Department of Health

Sir,

In compliance with the requirements of Republic Act (RA) No. 4688 and Administrative Order
(AO) No. 2007-0027, I have the honor to apply as head of:

COTABATO SANITARIUM
Name of Clinical Laboratory
Brgy. Ungap, Sultan Kudarat, Maguindanao
Address of Clinical Laboratory

I. Name of Applicant: SHERJAN P. KALIM, MD, DPSP

Landline No.: None Mobile No.: 0917 971 3201
Address: 35 Don Abelardo St., Cotabato City

II. Education and Training (Use additional sheets if necessary):

Medical School/ Institution: University of Santo Tomas
Inclusive Dates/ Year Graduated: 2003

Specialty Board Date Certified Training Institution

1
PBP Anatomic Pathology
PBP Clinical Pathology
PBP Anatomic and April 23, 2009 Philippine General Hospital
Clinical Pathology
Others: Specify

III. List all clinical laboratories supervised/ headed or associated with:

Name and Address of Clinical Laboratory Working Time Work Schedule

A. As Head
B. As Associate at CRMC, Cotabato City 8am – 5pm 8am – 5pm

I hereby certify that the foregoing statements are true. I assume full responsibility that the
operation of the clinical laboratory is in accordance with the Rules and Regulations pursuant
to RA 4688 and AO No. 2007-0027.

SHERJAN P. KALIM
Signature over Printed Name

___________________
Date

1
PBP – Philippine Board of Pathology
Form-CL-Head-A
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 List of Personnel

Annex A
Name of Laboratory : COTABATO SANITARIUM
Address of Laboratory : Brgy. Ungap, Sultan Kudarat, Maguindanao

Highest Educational Valid Date of Birth

Name Designation/ Position PRC Reg. No. Signature
Attainment From To (mm/dd/yr)

SHERJAN P. KALIM, MD, DPSP Pathologist Doctor of Medicine 0103706 07/14/2016 08/27/2019 08/27/1978
Chief Medical
ALBARAH S. MEDITAR, RMT College Graduate 0054965 11/22/2018 11/21/2021 11/21/1977
Technologist
Assistant Chief
SOFIA S. WAHAB, RMT College Graduate 0031945 02/15/2017 03/07/2020 03/07/1970
Med. Tech.
Medical
MICHELLE O. OCSIO, RMT College Graduate 0043500 02/15/2017 03/10/2020 03/10/1979
Technologist I
ALIANNA ARNICA A. Medical
College Graduate 0067005 12/08/1993
MAMBATAO, RMT Technologist I
Medical
NARISA U. OMAR, RMT College Graduate 0064013 12/14/2016 04/30/2020 04/30/1993
Technologist I
Medical
NORMIA A. TAHIR, RMT College Graduate 0056445 02/15/2017 05/10/2020 05/10/1981
Technologist I
Laboratory
HILDA Y. DIMA College Graduate N/A N/A N/A 11/06/1971
Technician I
Laboratory
BAI MEXICAN C. MASABPI College Graduate N/A N/A N/A 12/30/1983
Technician I
MARGUIANA A. DALAMBAN, Medical
College Graduate 0075674 09/19/2016 12/03/2019 1203/1994
RMT Technologist

Annex A- List of Personnel

Form-GCL-LTO-A
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 List of Equipment2

Annex B
Name of Laboratory : COTABATO SANITARIUM
Address of Laboratory : Brgy. Ungap, Sultan Kudarat, Maguindanao

Brand Name & Model Serial No. Quantity Date of Purchase

Centrifuge: Digisystem/DSC-156 DSC156MF 1 10/14/1996

Centrifuge: Digisystem/DSC-154 9701205-54 1 09/14/1998
Oven: Memmert/UM 100 UM 100 1 12/24/1998
Microscope: Olympus/CX-21 OA82326 1 11/18/2009
Microscope: Olympus/CX-21 OA82529 1 04/13/2015
BB Ref.: Panasonic/MBR-704GR-PK 12010005 1 03/10/2015
Water Bath: Biobase/SX-1L2H BK2015011 1 12/01/2015
Microcentri.: Digisystem/DSC-100MH-1 14120502 1 12/06/2016
Chemistry: StatFax/4500 4500-4334 1 12/14/2016 (Tie up)
Aircon.: Koppel/KWR-09RBC 16004AC011 1 04/04/2017
Med. Ref.: Biobase/BXC-V20M 2GO5F 1 10/2017
Cepheid/GeneXpert 815277 1 12/2017
Biomed.Freezer: Panasonic/MDF-U334 13100399 1 2017
Immuno.: Biomerieux/Mini Vidas IVD5211726 1 4/2018
Grifols/ DG Spin 320-0006251 1 4/2018
Grifols/ DG Therm 319-0005282 1 4/2018
Annex B- List of Equipment
2 Form-GCL-LTO-A
Equipment shall be functional and Revision:01
present in the clinical laboratory applying for license to operate.
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 List of Equipment3

Annex B
Name of Laboratory : COTABATO SANITARIUM
Address of Laboratory : Brgy. Ungap, Sultan Kudarat, Maguindanao

Brand Name & Model Serial No. Quantity Date of Purchase

Electrolytes: Horron/H900 E28095418 1 8/14/2018

Hema.: Mindray/BC-5100 RE-18100378 1 8/14/2018
Hema.: Medicalsystem/MS-H650 MSH65020180426010 1 8/23/2018

Annex B- List of Equipment

Form-GCL-LTO-A
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Equipment shall be functional and present in the clinical laboratory applying for license to operate.