Application for Grant of Registration of Eye Bank, Corneal Transplantation Center, Eye Retrieval Center under Transplantation of Human Organs Act

UBIN Details

UBIN

Select Office *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

I. EYE BANKING

(A) EYE BANK & Institution affiliated Ophthalmic/General Hospital

1.Name

2.Address

3.Select type

Government

Private

Voluntary

4.Select Type

Teaching

Non Teaching

5. IEC for Eye Donation :

(B) REMOVAL OF EYE BALLS AND STORAGE

1. Availability of adequate trained and qualified Personal for removal of eye balls/cornea ?

2. Name, qualification & address of the designated staff who will be doing whole globe / cornea retrieval :

Sl No

Name

Qualification

Address

Sl No

Name

Qualification

Address

3. Availability of following as per requirement :

(a) Whether register maintained for tissue request received from surgeon of corneal transplant centre :

Mobile Number

(d) Sets of Instruments for removal of whole globe/Cornea as per requirement :

(e) Special bottles with stands for preservation of eye Balls / Cornea during transit :

(f) Suitable preservation media :

(g) Biomedical waste disposal :

(h) Uninterrupted Power supply :

1. In charge / Director (Ophthalmologist) :

2. Eye Bank Technician :

3. Eye Donation Counselors (EDC) :

4. Multi task Staff (MTS) :

(D)Space requirement for eye Banks ( 400 sqft minimum )

(E) RECORDS

1. Arrangement for maintaining the records :

2. Arrangement for registration of pledges/donors and maintenance of utilization report :

3. Computer with internet facility and printer :

(F) EQUIPMENT

1. Slit lamp Bio microscope :

2. Specular Microscope for Eye Bank :

3. Laminar flow (Class II) :

4. Sterilization facility (In-house or outsourced) :

5. Refrigerator with temperature monitoring for preservation of Eyeballs/ Cornea :

(G) LABORATORY FACILITIES

1. Facility for HIV, Hepatitis B & C testing :

2. In no where do you avail it? Please mention Name and address of Institute :

3. Facility for culture and sensitivity of Corneoscleral ring. :

(H) RENEWAL OF REGISTRATION

1. Period of renewal 5 years after last registration :

2. Minimum of 500 corneas to be collected in 5 years :

3. Maintenance of eye bank standards (as per Guidelines) :

II. EYE RETRIEVAL CENTRE (ERC)

(A) RETRIEVAL CENTER – A Centre affiliated to an EYE Bank

Name

Address

Select type

Government

Private

Voluntary

Select Type

Teaching

Non Teaching

5. Information, Education and Communication Activities for Eye Donation :

6. Name of Eye Bank to which ERC is affilited :

(B) REMOVAL OF EYE BALLS AND STORAGE

1. Manpower: Adequate trained and qualified personal for removal of eye balls/cornea(In detail) :

a. In charge / Director :

b. Technician :

c. MTS (Multi task staff) :

2. Transport facility (or outsource) with storage medium

Sl No

Name

Qualification

Address

Sl No

Name

Qualification

Address

(D) AVAILABILITY OF FOLLOWING

1. Ambulance/ vehicle or funds to pay taxi for collecting eye balls from Outside :

2. Sets of instruments for removal of Eye Balls / Cornea

3. Special bottles with stands for preservation :

4. Eye balls/cornea during transit :

5. Suitable preservation media :

6. Waste Disposal(Biomedical Waste Management) :

7. Mobile Number :

8. Space requirement(Designated area) :

(E) RECORDS

1. Arrangement for maintaining the records :

(F) EQUIPMENT

1. Sterilization facility :

2. Refrigerator temperature control 24 hrs for preservation of Eyeballs/Cornea. (power back up) :

3. The retrieval centre is affiliated with an eye bank and Eye Bank is only authorized to distribute corneas :

III. CORNEAL TRANSPLANTATATION CENTRE

(A)

1. Name of the Transplant Centre / Hospital :

2. Address :

3. Government / Private / Voluntary :

4. Teaching / Non teaching :

5. IEC for Eye Donation :

6. Name of the registered Eye Bank for procuring tissue

(B)

1. No. of permanent staff members with their designation :

Sl No

Name

Designation

Sl No

Name

Designation

2. No. of temporary staff with their designation :

Sl No

Name

Designation

Sl No

Name

Designation

3. Trained persons for Keratoplasty and Corneal Transplantation with their names and qualifications: 2 (one Corneal Transplant surgeon should be on the pay roll of the Institute) :

SL No.

Name

Qualification

SL No.

Name

Qualification

(D) OT facilities :

(E) Safe Storage facility :

(F) Records Registration and follow up :

(G) Any other information :

Date

Place