bs-application form only
TRANSCRIPT
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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
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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&'&$.
SAMPLE PROFORMA FOR BIO-DATA OF FAC!LTY MEMBERS
1. Name :
2. Ae'Date of 4irth :
3. Present AddressPHOTO
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4. Professional Bualifications
C&,+# N$# 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
7eachin'Professional
7eachin'Professional
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
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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(((((((((((((
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Amount (((((((((((
'ame of the Ban$ "ith issuing branch (((((((((((((((((((((((((((((((
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
inature of &ead of the De!artment inature of &ead of Instt
%edicalu!erintendent
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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
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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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