Annex “E”

Professional Regulation Commission

INSPECTION AND MONITORING ADMINISTRATIVE TOOL

(ACD-IAM-05)

Date of Inspection/Monitoring: ____________________

Professional Regulatory Board of/for: _______________________
Name of Educational Institution/Establishment: __________________________________________________ Contact Numbers: (landline)
____________________
Address: __________________________________________ E-mail address: _________________________(mobile) ____________________
Name of the Authorized Representative: ___________________________________________________ Position: ____________________________________

Name of Profession and Date of Validity of the Certificate of Compliant with the Membership with Other Scope of Workload (e.g.
Employees who Registration/ Professional Registration displayed CPD requirement AIPO/APO Applicable Work subjects being
are Registered Identification Card in the office/clinic/ Requirements taught, patients
License No. (√) – compliant (√) – Active
and Licensed being handled,
laboratory/drug store
Professionals (×) – not compliant (×) – Inactive etc.)
(√) – displayed
(N/A) -if not applicable (N/A) – if not applicable
(×) – not displayed

(N/A) – if not applicable

Names of other Qualifications/ Scope of Work Workload

Employees/Staff
 Credentials

______________________________________________
Name and Signature of Commission/PRC
Representative

Date: ______________________