Application for Grant of Permanent Registration of Clinical Establishment

UBIN Details

UBIN

Select Office *

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I.ESTABLISHMENT DETAILS

1.Name of the establishment :

2.Address of the establishment:

Street Name 1 *

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Street Name 2

Town/Village

Country

State

District

Postal / Zip Code

Block

E-Mail

Mobile Number

Website (if any)

Date of Starting

4. Location:

Description :

Select type

Non Government Sector

Private Sector

6. Name of the owner of Clinical Establishment:

Address

Street Name 1 *

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Street Name 2

Village/Town

Country

State

District

Postal / Zip Code

Block

E-Mail

Mobile Number

Website (if any)

7. Name, Designation and Qualification of person in-charge of the clinical establishment:

Sl No

Name

Designation

Qualification

Registration Number

Name of Central/State Council

Mobile

Email ID

Sl No

Name

Designation

Qualification

Registration Number

Name of Central/State Council

Mobile

Email ID

8. Systems of Medicine offered: (please tick whichever is applicable)

II.TYPES OF SERVICE

TYPE

SPECIALITY SPECIFIC

Medical Specialties – for which candidates must possess recognized PG degree(MD/Diploma/DNB or its equivalent degree)

Surgical specialties

Medical Super specialties

Surgical Super specialties

III INFRASTRUCTURE DETAILS

10.a. Area of the establishment (in sqft):

b) Constructed area:

11.1 Total no. of OPD Clinics:

11.2 Specialty-wise distribution of OPD Clinic.

Sl No

Speciality

Sl No

Speciality

12. 1. Total number of beds(In-Patient Department)

12.2. Specialty-wise distribution of beds, please specify (In-patient Department)

Sl no

Specialty

Beds

Sl no

Specialty

Beds

13. Biomedical waste Management

13.1 Method of treatment and /or disposal of Bio- medical waste

13.2.Whether authorization from Pollution Control Board/Pollution Control Committee obtained?

IV HUMAN RESOURCES

No. of permanent staff :

No. of temporary staff:

Please furnish the following details:-

Sl No

Name

Category of staff

Qualification

Registration

Nature of service Temporary/Permanent

Sl No

Name

Category of staff

Qualification

Registration

Nature of service Temporary/Permanent

Support Staff :

Sl No