1. NAME OF THE CANDIDATE

2. MOTHER’S NAME

3. FATHER’S NAME

4. GENDER 5. CATEGORY 6. NATIONALITY

Male GEN ST Indian Other’s Female SC OBC If Other Specify

7. PROGRAM APPLYING FOR 8. DATE OF BIRTH (As in candidate’s Class X mark sheet or equivalent certificate)

House Keeping/Fitter Ward Attendant/ D D Y Y Y Y M M

9. PHYSICAL CHALLENGED CATEGORY 10. % OF DISABILITY

11. ADMISSION CATEGORY 12. HOSTEL ACCOMODATION Sponsored Non-Sponsored Yes No

13. CONACT NUMBERS Mobile Number Landline Phone Number with STD (Area) code

14. E-MAIL ADDRESS (IF ANY) 15. MARITAL STATUS Married Unmarried @

16. Write your complete correspondence address including your name in English in Capital letters with Black Pen

(For all communications related to your admission)

Name :______________________________________________ Address: ____________________________________________ ____________________________________________________ ____________________________________________________ Dist.:_____________________ State :_____________________ Country : _________________ Pin : _____________________

17. PHOTOGRAPH (within the Box Only)

18. SIGNATURE OF THE CANDIDATE (Within the Box Only)

19. LEFT HAND THUMB IMPRESSION (Within the Box Only)

Please affix one recent color

photograph of size 3.5 X 4.5cm

APPLICATION FORM # For the Academic Year INSTRUCTIONS 1. Please read the instructions in the Admission Pro-

spectus before filling this form. 2. Write in CPITAL LETTERS only within the box

by using BLACK BALL POINT PEN Only. APPLICATION FORM

20. WRITE YOUR COMPLETE PERMANENT ADDRESS

Name of the Examination

Passed

Name of the Board/Council/

University/Examining Body

School/College/ University/

Institution from which passed

Maximum Marks (without Extra Optional)

Marks Secured (without Extra

Optional)

Year of Passing

Address Village /City District State Country

Pin Code

21. EDUCATIONAL QUALIFICATION

22. LANGUAGE KNOWN

23. ID PROOF TYPE 24. ID PROOF NO.

25. BLOOD GROUP

26. SIGNATURE • I hereby certify that the information given in the application (all relevant forms) is complete and accurate • I understand and agree that misrepresentation or omission of facts will justify the denial of admission, the cancellation of ad-

mission or expulsion. • I have read, understood and do hereby consent to the term & conditions for admission as mentioned in Admission Prospectus. • I have enclosed photocopy of all the supportive documents mentioned in the application form. Candidates Signature : ______________________________________________ Date : ______________________________

INSTRUCTIONS • Please fill the admission Form and deposit the same at the Registration Counter of Kalinga Eye Hospital, Dhenkanal before

21st May 2016. • Original documents to be produced for verification at the time of admission. No form will be accepted without verification Annexure • Attested true copies of mark sheets and certificates of all examinations you have mentioned in the Application. • An attested true copy of the conduct certificate from the institution last attended • An attested true copy of the caste certificate. • The attested true copies of other certificate as required. • Three copies of recent color passport size photographs. • Original Money receipt of the application form should be submitted along with the application.

FOR OFFICE USE ONLY Roll No………….. …………For the Course ………………………………………………………… admitted/not admitted

Date : Director

Certificate Course on Vision Technicians

(One year full time course)

Who can attend? This training is designed for young enthusiastic persons and or refractionists with a desire to increase their knowledge and clinical skill along with an attitude towards planning, implementing, monitoring and evaluating activities towards carrying out the Vision Technician practice efficiently.

Eligibility Criteria • Passed +2 in any stream • Working knowledge in Basic English

This course is open for all residents of India of maximum age of 40 Years as of 02.01.2019. Admission is limited to 20 participants per batch-per year & selection will be made after final interview subject to meeting the eligibility criteria.

Application

• Applicants are requested to download application forms from our website www.kalingaeyehospital.org and send the completed form to the course coordinator and deposit Rs 100.00 as application fee at the admission cell. Or the application can also be purchased directly from the admission cell by paying Rs 100.

• If case of difficulty in downloading the form you can contact the course coordinator to get the forms by email within five working days.

• Have to submit all your qualification supporting documents along with the original application fee money receipt with the application form

• Last date of receiving application forma is 5Pm of November 30 of 2018.

• Scrutinized applicants will be asked to attend the in-terview on 2nd Saturday of December and if selected then admission has to be made immediately

• Classes will commence from 2nd January 2019 • On admission the student has to submit his/her last

original CLC.

The Course Fee The Course fee is Rs 15,000.00 per student and it s to be paid in full at the time of admission. The amount is non-refundable. The course fee includes Admission Fee, Faculty Fees, Exam Fees, Certification Fee and Class notes. This fee doesn’t cover the uniform, I-Card, Student Diary, any travel, Books, Teaching Learning Materials, Canteen charges and Hostel fees.

Canteen Students can purchase their food from the canteen at a subsidized rate or run the own student canteen on sharing basis..

Examinations Student attendance is much important and any student fails to meet 85% attendance will not able to attend the exam.

Where to stay? The classes will be conducted at Kalinga Eye Hospital, Govindpur unit as well as at the Dakhinakali unit too.

Accommodation Hostel Facilities are available at Kalinga Eye Hospital, Govindpur unit and the maintenance charges per students per bed are Rs 500 per month. This is for Bed, Electricity and Water charges only.

Hospital Manager, Kalinga Eye Hospital, Dakhinakali Road, Dhenkanal, Odisha, 759001, Tel- +916762223949, +916370907619 Email.:vtcourses@gmail.com Website.:www.kalingaeyehospital.org

Contact

Why I should apply Looking at the need of employment, Kalinga Eye Hospital has designed a course in affiliation to the Government of India’s Ministry of Skill Development and Entrepreneurship, where qualified students can opt to build their career in Eye Care. With this one year full time certificate course, one can work in any Eye Hospital across India as Vision Technician or even think of setting up his/her own primary eye care centre.

Kalinga Eye Hospital felt that there is a need for a permanent eye care facility that could provide primary eye care to rural population. Hence it started establishing primary eye care centers (also known as Vision Centre) in rural areas

A vision centre is a primary eye care centre that would serve a rural population of 50,000 - 70,000 on permanent basis. The functions of vision center are

To discharge the functions of the vision center effectively, customized training of refractionists is necessary based on the skills necessary to run a vision center successfully. The course will primarily focus on enhancing the skills of refraction practitioners, to upgrade their knowledge and to augment their ability in planning, organizing and execution

Objectives

The aim of this course is to help the candidates

• Comprehensive Eye examination. • Diagnosis and treatment of simple external eye

diseases. • Delivering spectacles on the spot to correct

refractive errors. • Diagnosis of diabetes through blood sugar

examination and counseling appropriately. • Helping the patient to interact with ophthalmologist

in the base hospital through teleconference about the diagnosis and treatment.

• Diagnosis of secondary and tertiary eye problems and referring them appropriately to the base hospital.

• Check vital signs and do simple lab tests • Perform basic outpatient procedures • Examine the eye for eye diseases • Use necessary instruments to identify and assess eye

disorders • Maintain necessary details in the medical records in

the proper format • Learn basics of counselling skills • Learn basics of optical counseling

• Process and dispense spectacles

• Dispense ocular drugs

• Use computers for processing data , create reports and maintain data

• Register the patients and do the billing • Use of Video Calling facility for consultation and

expert advice • Use management principles in running the Vision

Centre • Organize camps and follow up camp with the

support from base Hospital

How will you learn? Training Methodology

• Lectures and demonstrations • Videos, PPTs • Observation • Discussion sessions • Practice sessions • Hands-on training • Situation analysis study, seminars and case

presentation • Out reach camps and Vision centres posting

Evaluation Pattern

• Maintaining log book

• Weekly evaluation

• Practical Examination

• VIVA VOCE

• Final Exam (Theory & Practical)