MINISTRY OF HEALTH
STATE DEPARTMENT FOR MEDICAL SERVICES
UNIVERSAL HEALTH COVERAGE (UHC) STAFF HEAD COUNT FORM
1. PERSONAL BIO – DATA
Name of Officer: …………………….…..........................................................................
Gender: ………………………………………………………………………………………….
ID. No: …………...................................Employment/P/No: ………...............................
Designation...................................................................... Job Group ............................
Terms of service: …………………………..……………………………………………………
Contract Start Date……………………………….Contract End Date…………………………
Current Work County......................................................................................................
Work Station……………………………............................................................................
Postal Address: ……………..........................…………………………….............................
Mobile Phone No(s)........................................................................................................
E-mail address: … …….…...............................................................................................
When did you last receive salary (month/year) ……………………………………………….
Bank………………………………………. A/C No.………………………………………….…
I, ……………………………………………………………of ID Number……………………………the
undersigned, hereby declare that all information provided in this document is true, accurate, and
complete to the best of my knowledge and belief. I understand that providing false or misleading
information may result in penalties, legal consequences, or rejection of this information under the
applicable laws of Kenya. I further acknowledge that the State Department for Medical Services reserves
the right to verify the information provided, and I agree to cooperate fully with any such verification
process.
Signature………………………………………Date………………………………………………
Note: For UHC Staff Only Ensure that you fill the online Universal Health Coverage (UHC) Staff
Headcount Form available on: https://forms.gle/VektZTKoH3DBu1r7A before submission of this form.
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2. DETAILS OF THE CURRENT SUPERVISOR (to be filled by the immediate supervisor)
I confirm that the officer works under my supervision
Name of Supervisor ...............................................Employment/P/No:.............................
Designation ......................................................................................................................
Duty Station ………………………..……............................................................................
Email Address ............................................ Mobile Contact .............................................
Signature & stamp.................................................................. Date ..................................
3. DETAILS OF THE COUNTY HUMAN RESOURCE OFFICER FOR HEALTH
I confirm that the officers above work in the County Government
of…………………………………..
(Tick below)
UHC Staff: Yes No
Current Supervisor Yes No
Name of County HR Officer.......................................Employment/P/No:.............................
Designation ...........................................................................................................................
Duty Station ………………………..…….................................................................................
Email Address ............................................ Mobile Contact .......................................
Signature & stamp.................................................................. Date ..................................
FOR OFFICIAL USE ONLY
CHIEF OFFICER INCHARGE OF HEALTH
I ………………………………………………… Chief officer for health confirm / do not confirm
that the officer is an employee of the county of ……………………… under the Universal
Health Care (UHC) program.
Signature & stamp.................................................................. Date ..................................
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COUNCIL OF GOVERNORS REPRESENTATIVE
The officer Appeared for the headcount: Yes No
Remarks:
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………………………….………
……………………………………………………………………………………………………….
COG Representative (Name)..............................................P/No...............................................
Designation ....................................................................................................................
Signature ............................................................Date.................................................
STATE DEPARTMENT FOR MEDICAL SERVICES HUMAN RESOURCE REPRESENTATIVE
The officer is in the current Payroll: Yes No
Remarks:
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………………………………………………………….…………
…………………………………………………………………………………………………………….
SDMS HR Official(Name) .............................................Employment/P/No:……………………
Designation ....................................................................................................................
Signature ............................................................ Date.................................................
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