Form MW-INT-01 v1.1

Health Facility Integration Requirements & Readiness Assessment

A DHA-certified bridge between your existing hospital system and the national Health Information Exchange and SHA claims

Form header

Facility *

Form Ref. MW-INT-01 /

Level / Location

Date of visit

Email Address *

Phone Number *

Facility lead

Mwavuli360 lead

A1. Facility particulars

Registered facility name

Trading / display name (if different)

Facility level

Number of Facilities/Branches

Ownership (Private / Faith-based / NGO / Public)

Physical address & building

County / Sub-county / Ward

Number of beds (inpatient)

Number of maternity beds

Daily Number of Patient Visits

Number of Workers (total staff)

Number of Stations (computers / service points)

A2. Key contacts

Name a single Integration Focal Person. All technical correspondence goes to one named person.

This part determines whether integration is possible at all, and in what form. Answer it before anything else.

B1. Does the facility currently run a computerized hospital system?

Yes, a full HMIS/EMR Yes, billing/claims software only Partially (some departments) No, paper based

B2. Current system identification

If the facility runs more than one system, describe the primary system here and name the others in the last row.

System / product name

Vendor / supplier company

Version currently in use

Year installed

Number of branches or instances running this system

Database used (if known)

Vendor support contract in place? (Yes / No / Expired)

Any other systems in use (name each)

B3. Modules present in the current system

Tick one box per row. Leave a row blank only if the facility genuinely cannot tell.

HMIS module	Available	Not available

B4. System deployment and connectivity Is the current system online or offline?

Online — hosted on the internet / cloud, reachable from outside the facility Offline — installed on-premise only, no internet connection to the system Hybrid — on-premise server with internet access for some functions

Does the facility have a working internet connection?

Yes, permanent Yes, intermittent No

Internet provider & link speed

Server location (on-site room / data centre / cloud provider)

Backup power available for the server (Yes / No)

Your answers are saved in this browser as you type.

End of form MW-INT-01 v1.1