bs-application form only

8/13/2019 Bs-Application Form Only

1/16

All information has to be typed. Application with hand writteninformation will summarily be rejected.

8. APPLICATION FORM

FOR

FRESH / RENEWAL OF ACCREDITATION IN DNB- BROAD SPECIALTY

NAME OF THE SPECIALTY:

PART- A (i)

CONTACT DETAILS

1.

Name and Address of the Institution:

Phone Number:

Fax Number:Email-ID:

Website:

2 Year in which established:

3

Year in which 1st fresh renewal was

ranted and total number of renewal

ranted thereafter

4 Date of Ex!ir" of #ast $enewal

DETAILS OF TOP LEEL F!NCTIONERIES OF THE INSTIT!TE

"

H#$% &' # I*+i,#DNB P&$#

C&&%i*$&

A++i+$* P&$#

C&&%i*$&

NameDesination

%obile Number

Phone Number

Fax Number

Email-ID

0

%anaement of the &os!ital'Institute:

(Please t"!e the correct o!tion in riht most

blan) column*

+o,ernment

Defence er,ices

$ailwa"s

Public ector

%edical .ollee

Pri,ateAn" /ther

Is the &os!ital reconi0ed for Internshi! &ouse ob P+'Post

doctoral courses in the disci!line'(s* of s!ecialt" in which the

accreditation is'are re2uired3

8Please mention other disci!lines which are reconi0ed for %D'%

or D%'%.h courses


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PART-A (ii) ENERAL INFORMATION

T&$ N,5# &' 5#%+ i* # H&+6i$/I*+i,#:

Number of +eneral 4eds5:

Number of Pa"in 4eds:

Number of ubsidi0ed 4eds:

17 Annual 4udet for !recedin three "ears:

114alance heet6 Fixed Assets #ist

(Please enclosed co!" of I7$'balance sheet for last 8 "ears*

12Assets (9alue in $u!ees*

Please attach list%o,able'Immo,able

13 P+i9$ I*'$+,9,# '& T#$9i* +,%#*+:

Number of eminar $ooms'.onference $ooms

Number of 7eachin $oom in the ward'Patient accommodation area

Number of 7eachin $oom in the /PD

Details of facilit" for hands-on-ex!erience

(E .linical )ills #ab6 Penta &ead %icrosco!e etc*

14 Please s!ecif" the audio,isual aids a,ailable in the teachin rooms:

1" R#+i%#*i$ F$9iii#+ i* # &+6i$/i*+i,#:

Number of Accommodation

For P+ tudents

For $esidents

For .onsultants

For Nursin taff

Number of $ooms on sharin basis

Number of sinle rooms

Whether Facilities for attached toilets

a,ailable:

Yes'No'.ommon

7oilets

10 A&,* &' +i6#*% & #+i%#*+ i* # &+6i$/i*+i,# 6# &*

Amount !aid in the !recedin "ear

(In case of renewal6 )indl" !ro,ide the !roof

of last three "ears*

Y#$ I

Y#$ II

Y#$ III

1S#9,i D#6&+i 5#i* 9$#% '&

# DNB $i*##+:

Yes'No

(If "es mention the

amount*

18 D#$i+ &' C&*+,$*+ S$'' ;&


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iii Nursin er,ices Number of Nurses

i= Whether reconi0ed for trainin of nurses

Di!loma

Deree

Post +raduation= 7otal number of Para-medical taff in hos!ital:

=i 7otal number of r $esidents in hos!ital:

=ii 7otal number of ;r $esidents in hos!ital:

1

7otal number of De!artments in the hos!ital

(Please enclose list indicatin the desinated De!artments with their

&/Ds*

27Whether the hos!ital is enaed in an" litiation aainst N4E

(Please enclose the list of cases alon with the title of the cases*

21

Please i,e details of other accreditation recei,ed b" the a!!licant

hos!ital'Institute such as NA4#6 NA4&6 ;.I6 I/ etc

(Please !ro,ide details namel" accreditation awarded and date of

award*

22Financial standin for last three "ears (!rofit loss statements* and

Audited balance sheet

23

Whether reistered as a charitable or tax exem!t with the income

tax de!artment If "es details of PAN number6 Income 7ax

Exem!tion cateor"

24W## $ #,$& 9#$$*9# $=$i$5#:

(Please enclose the co!" of a,ailable clearance*

S6#9i' Y#+/N&

i A!!ro,al for clinical'teachin establishment

ii Fire afet"

iii 4uildin .om!lex'/ccu!anc"

i, #ocal Authorit"'munici!al clearance etc

, .ertificate of incor!oration

PART -B


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SPECIALTY SPECIFIC INFORMATION

NAME OF THE SPECIALTY:

2" i 7otal Number of beds in the s!ecialt" a!!lied for DN4

Number of +eneral 4eds5 in the s!ecialt" a!!lied for

DN4

Number of Pa"in 4eds in the s!ecialt" a!!lied for

DN4

Number of ubsidi0ed 4eds in the s!ecialt" a!!lied for

DN4

ii Number of beds in the .asualt" er,ices in the s!ecialt"

iii Are casualt" ser,ices a,ailable round the cloc)

i, Whether $esidents are ex!osed to handle emerenc" ser,ices

, Number of beds in the I.> i* # +6#9i$ %,i* # 6#9#%i* ## 9$#*%$ #$+

Y#$

T&$ N,5# &'

P$i* P$i#*+

$%i#%

T&$ N,5# &'

#*#$ P$i#*+

$%i#%

T&$ *,5# &'

6$i#*+ $%i#% &*

+,5+i%i?#% 5#%+

$*% T&$

2 OPD #9&%>> i* # +6#9i$ %,i* # 6#9#%i* ## 9$#*%$ #$+

Y#$N,5# &' P$i*

P$i#*+

T&$ N,5# &'

#*#$ P$i#*+ +##*

i* OPD>

T&$ *,5# &'

6$i#*+ +##* &*

+,5+i%i?#% $#+5#%+

$*% T&$

28Number of times /PD is held in a wee) Please s!ecif" the timin of

/PD


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2

Is the /PD attended b" all facult" members'consultant of the unit3

(If "es6 s!ecif" examination'Assist the examination Pro,ide onl"

Ancillar"

37 Do the $esidents examine the /PD cases3

31&as the Institution !ro,ided an" s!ecial facilities for /PD trainin

for the $esidents (Please name the facilities*

32

i Deficiencies'.omments of the a!!raiser communicated to the

institution and the action ta)en thereon (Please attach a se!arate

sheet6 if necessar"*

ii T$9 R#9&% &' $ # 9$*%i%$#+ #i+##% ;i #

i*+i,i&* i* i+ +6#9i$ & 5# 'i#%. (I* 9$+# &' #*#;$ &*)

1 Number of $eistered .andidates

= Number of .andidates left

8 Number of .andidates a!!eared

> Number of .andidates Passed

? Number of .andidates Failed

SPECIAL CLINIC

33N$# &' +6#9i$ 9i*i9+ ($+ #$#% & # +6#9i$) $*% # *,5# &' i#+ #

9i*i9 i+ #% i* $ ;##


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3" F& S,i9$ $*% $i#% +6#9i$i#+ &*:

Please !ro,ide detailed information on the followin on a se!arate sheet

(a) taff in Anesthesia de!artment with their 4io-data

(b) Pre-anesthesia .linic

(c) E2ui!ment in Anesthesia de!artment

(d) Number of minor /7s

(e) Number of maor /7s

(f) E2ui!ment in /7s

(* Post o!erati,e ward

(h* #abor rooms

(i* Neonatolo"


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e Photoco!" Facilit"

f /nline ;ournals'#earnin resources

Number of .om!uters

h Internet Access

i #AN

Wi-fi Access

) Printer Facilities

l ubscri!tion to e-!ortals such as /,id'co!us etc

42

P#$+# i*%i9$# i' # i*+i,i&* $+ i$i+&* ;i $* i5$ i' +& 6#$+#

#*i&* i+ %i+$*9# '& # I*+i,i&*/H&+6i$. Y#+/N&

(A$9 # 6#i++i&* ## '& # 9&*9#*#% I*+i,i&*.)

RESEARCH METHODOLOY

43 In &ouse tatistician

44#ocall" a,ailable statistician

(Please Pro,ide Details*

Name

.ontact Details

Bualification

Protected time of statistician to su!!ort DN4 trainin in this

hos!ital'institute

4"$esearch Proects /noin: Please i,e details:

(If "es6 !lease enclose the details*

40Whether Ethical .ommittee exists for research

(if "es6 i,e com!osition and fre2uenc" of meetin*

RECORD @EEPIN

4Details of %edical records s"stem for the de!artment

(Please attach a co!" of the record form*

48Number and t"!e of maor o!erations !erformed in the s!ecialt" (Precedin three "ears*

Please attach list

4Number and t"!e of minor o!erations !erformed in the s!ecialt" (Precedin three "ears*

Please attach list

"7 Number of da" care sureries durin the last three "ears Please attach list

"1Please attach the list indicatin the number and t"!e of emerenc" o!erations !erformed

durin the last three "ears (Year wise*

P#$+# $$9 %#$i+ &' H$*%+ &* T$i*i* '& DNB 9$*%i%$#+ %,i* ## #$+.

P#$+# #'# & 9,i9,, '& 9&*#*+ & 5# 9&=##% i+ I II III Y#$+.

"2 Whether students had maintained #o 4oo) as !er 4oardCs sam!le

F!LL TIME STAFF IN THE SPECIALTY: Please attach co!u" of salar" sli!s and

income tax form-1 for each reular staff for last one "ear Please also attach underta)in


8/16

from them that the" would not lea,e the hos!ital for at least three "ears and in case of

such and e,ent6 the hos!ital will re!lace the staff within three months failin which

National 4oard of Examinations ma" ta)e a!!ro!riate action for not allowin the next

batch of DN4 candidate in the s!ecialt"

"3 $econi0ed P+ 7eacher: @indl" refer to definitions before ma)in these entries

N$# ,$i'i9$i&*T#$9i* E6#i#*9#

$'# P&+ $%,$i&*

N&. &' R#+#$9

P,5i9$i&*+

"4r';r .onsultants (ha,in minimum '? "ears ex!erience res!ecti,el" after !ost

raduation in the s!ecialt" showin whole time basis*:

N$# ,$i'i9$i&*E6#i#*9# $'# P&+

$%,$i&*

N&. &' R#+#$9

P,5i9$i&*+

"" /ther .onsultants (not on whole time basis*

N$# ,$i'i9$i&*E6#i#*9# $'# P&+

$%,$i&*

N&. &' R#+#$9

P,5i9$i&*+

"0

Whole time r $esident with !ostraduate deree in the s!ecialt" (DN4'%D'% or

D%$D'D%$7'D$%* Please note that the DN4 candidates underoin trainin in the

de!artment should not be shown as enior $esidents

N$# ,$i'i9$i&* E6#i#*9# $'# P&+ N&. &' R#+#$9


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$%,$i&* P,5i9$i&*+

" Whole time $esidents without P+ 2ualification6 sta"in the cam!us

N$# ,$i'i9$i&* E6#i#*9#N&. &' R#+#$9

P,5i9$i&*+

N: P#$+# $$9 # Bi&-%$$ &' # $5&=# +$'' i* # #*9&+#% 6&'&$.

SAMPLE PROFORMA FOR BIO-DATA OF FAC!LTY MEMBERS

1. Name :

2. Ae'Date of 4irth :

3. Present AddressPHOTO


10/16

4. Professional Bualifications

C&,+# N$# Y#$ &' P$++i* N$# &' !*i=#+i

%44

%'%D'D%'%.h'DN4

(Please mention s!ecialt"*

S6#9i$

/ther Bualification:

(Please !ecif" .ourse*

C&,+# N$#

5. Ex!erience after P+ deree

D,$i&* H&+6i$/I*+i,i&* P&+/D#+i*$i&*

#%

E6#i#*9# $+

(P#$+# i9< # 9 &6i&*)

7eachin'Professional





7eachin'Professional(Details of teachin ex!erience as !er N4E criteriaplease refer Clauses 7.1.2 for details)

No of Publications:Indexed other recognized Journals(Details as !er N4E criteria*

tatus in the &os!ital Full-7ime

Part 7ime Number of &ours s!ent

!er da":

Post !resentl" held in the &os!ital and from which dateG Details of examinershi! in other uni,ersities:

1H Please attach !roof of wor)in in the hos!ital in the form of salar" sli!s and Income tax

F-1 form for the last one "ear

11 Please also attach an underta)in b" the consultant that he'she will not lea,e the

hos!ital in the next three "ears and s!end at least -1H hours !er wee) for trainin of

DN4 candidates (attach underta)in for whole time status as !er N4E criteria*

1= An" other remar)s:

(inature*

"8Is the clinical wor) 'teachin orani0ed on a


11/16

01

Is the a!!ointment of staff in the de!artment

contractual for a limited !eriod or is a!!ointed

u!to su!erannuation3

02

No of research !ublications made b" the

de!artment staff and DN4 7rainees durinlast three "ears in reconi0ed ournals onl"

(submit list and co!ies of $e!rints*

03Details of arranement for trainin in basic sciences as !er N4E

criteria

04Please i,e list of field ser,ices !ro,ided b" the hos!ital'Institution

for communit" wor)

Please attach the se!arate

list in the i,en format

R,$/!5$*

A#$+

N,5# L&9$i&*

Di+$*9#

S$''

M#%i9$ P$$-M#%i9$

0"

Please refer to the National 4oard of Examinations curriculum in

the s!ecialt" a!!lied for and i,e the details how would "ou

!ro,ide the !ractical hands on trainin to these candidates(Please

i,e the details of co,erin the theor" s"llabus and !ro,idin the

desired !ractical s)ills durin the trainin !eriod of three

"ears* attach a se!arate sheet

Please give details of appraisal done in your specialty in last

2 years (for renewal cases only).

DETA! "# #EE$Applicable fee submitted as per Information Bulletin.

(Please add Rs. 3,000! to"ards the cost of Information Bulletin, to the Inspection fees#.

Ban$ %raft&hallan 'umber ((((((((((((((((((((((((((((( %ate of Issue(((((((((((((


12/16

Amount (((((((((((

'ame of the Ban$ "ith issuing branch (((((((((((((((((((((((((((((((

(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((

inature of &ead of the De!artment inature of &ead of Instt

%edicalu!erintendent


13/16

FORMAT-SPECIALTY WISE TRAC@ RECORD PROFORMA

(/N#Y F/$ $ENEWA# .AE F/$%A7*

Name of the &os!ital :Name of the !ecialt" :

Date of First $econition b" N4E :

No of .andidates Allowed !er "ear :

Date of Ex!ir" of Accreditation :

No of $enewal: First'econd'7hird

(.o!" of last accreditation letter shall be enclosed* :

No of

candidates

$eistered

Per "ear

Name of

candidates

with

address

Date of

reistration

Name of

collee

from

where%44

was

obtained

Year

session

of

!assin!rimar"

exam of

N4E

Due date

for

a!!earin

in finalexam

Due date of

actual

a!!earance

in finaltheor" exam

and no of

attem!t

Date of

a!!earin

in the

!racticalexam

Final

result

!ass'

fail inthe

final

exam

If the

candidates

has left the

Instt Durintrainin his

name and

reason for

lea,in the

instt


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PART C

DECLARATIONSAMPLE DECLARATION

S!BMISSION OF APPLICATION SEE@IN ACCREDITATION ON

BEHALF OF

M/S FOR

THE SPECIALTY.

I6 DrJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJaed JJJJJJJJJ

"ears resident of JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJactin in m"

official ca!acit" asJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJha,in its

reistered office at JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ do hereb" state

and affirm6 as under that:

1 7hat I am dul" authori0ed to act for and on behalf of %'sJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ

in

the matter of submittin this a!!lication before the National 4oard of Examinations at JJJJJJJJJJJJ

New Delhi

2 I am dul" authori0ed and com!etent to ma)e this submission before National 4oard ofExaminations

3 I am ma)in this submission in m" official ca!acit" and the facts stated in thisa!!lication are correct and based on official records

4 7hat this hos!ital 'institution has ot necessar" a!!ro,al for runnin the hos!ital 'institute

5 7hat this hos!ital 'institution underta)es has ot necessar" a!!ro,al for bio-medicalwaste6 use of x-ra"s e2ui!ment6 ultrasound e2ui!ment and com!l" with the fire safet"

rules in this reard

6 7hat this hos!ital 'institution underta)e to com!l" with the uidelines of National4oard of Examinations reardin le," of fee on DN4 candidate ' !a"ment of sti!end

7 7hat this hos!ital 'institution underta)e to re!ort an" chane in the ownershi! of thishos!ital' institute as and when it ta)es !lace within an outer limit of wee)s from the

same

8 7hat nothin in the accom!an"in a!!lication has been concealed or misre!resented

9 7hat this hos!ital 'institution would !refer' would not !refer !ri,ilee on the informationcontained in the accom!an"in a!!lication or an" !art thereof and should not re,eal to

an" third !art" exce!t with !rior !ermission of the a!!licant hos!ital ' institute

10 7hat this hos!ital ' institute has understood the terms6 conditions6 instructions etc in theinformation bulletin for accreditation and aree to abide b" the same

11 7hat this hos!ital ' institute )nows and declares that the urisdiction for an" dis!uteshall be at New Delhi onl"

12 7hat the accom!an"in a!!lication ser,in accommodation has been !re!ared andsubmitted b" the undersined onl"

13 7hat I ' We or this hos!ital has not souht ' ta)en the hel!' assistance of an aenc" 'aenc" or !art who is not em!lo"ee of the a!!licant orani0ation to !re!are6 submit

and ' or follow the accom!an" of a!!lication

14 I ' we are aware that can,assin and ' or use of an" aent ' aenc" to re!resent thea!!lication hos!ital ' institute shall lead to dis2ualification


15/16

N$# $*% Si*$,# &' #

H#$% &' # H&+6i$ (A%i*i+$i=# H#$%)

ANNEG!RES

1. $efer to Part A(ii* No G- Proof in su!!ort of total no of beds in the hos!ital

2. $efer to Part A(ii* No 11-.o!" of I7$'balance sheet for last 8 "ears

3. $efer to Part A(ii* No 1-.o!" of !a" sli! ($e!resentati,e sam!le for "ear 1 = and 8

(DN4 trainees*

4. $efer to Part A (ii*1G- #ist of desinated de!artments and &/D(s*

5. $efer to Part 4 (=*- Please i,e documents in su!!ort of IPD

6. $efer to Part 4 (=*- Please i,e /PD schedule

7. $efer to Part 4 (8H 81* - Please i,e details of the candidates

8. $efer to Part 4 (>H to ?1* )indl" !ro,ide details

9. $efer to Part 4 (?=* - Please !ro,ide sam!le of #o boo)

10. $efer to Part 4 (?8 to ?* - Please i,e 4io-data of all consultant as !er the sam!le 4io-data enclosed at the end of Part 4 (Point no ?*

11. $efer to Part 4 (?8 to ?* - Please enclose co!" of Form 1 in res!ect of each .onsultant

12.


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