Application For Renewal Of Registration Of Hospital To Carry Out Organ Or Tissue Transplantation Other Than Cornea

UBIN Details

UBIN *

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Select Office *

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Section

To The Appropriate Authority for organ transplantation (State or Union Territory)

We hereby apply to be recognized as an institution to carry out organ transplantation. The required data about the facilities available in the hospital are as follows :-

A. Hospital

Name *

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Location *

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Type of Hospital

Teaching/Non-teaching *

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Approached by *

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Total Bed Strength *

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Name of the disciplines in the hospital *

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Annual budget

Patient turnover/ year

B.SURGICAL FACILITIES

No. of beds

No. of permanent staff members with their designations

Sl no.

Name

Designation

Sl no.

Name

Designation

No. of temporary staff members with their designations

Sl No.

Name

Designation

Sl No.

Name

Designation

No. of operations done per year

Trained persons available for transplantation (please specify organ for transplantation)

(C) MEDICAL FACILITIES

1. No. of beds :

2. No. of permanent staff members with their designations :

Sl No.

Name

Designation

Sl No.

Name

Designation

3. No. of temporary staff members with their designations :

Sl No

Name

Designation

Sl No

Name

Designation

4. Patient turnover per year :

5. Trained persons available for transplantation (please specify organ for transplantation) :

Name

Specify organ for transplantation

Name

Specify organ for transplantation

6. No. of potential transplant candidates admitted per year :

(D) ANAESTHESIOLOGY :

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

Sl No

Name

Designation

Sl No

Name

Designation

2. No. of temorary staff members with their designations :

Sl No

Name

Designation

Sl No

Name

Designation

3. Name and No. of operations performed :

Sl no

Name

Operations

Sl no

Name

Operations

4. Name and No. of equipments available :

Sl No

Name

Equipment

Sl No

Name

Equipment

5. Total No. of operation theatres in the hospital :

6. No. of emergency operation theatres :

7. No. of separate transplant operation theatre :

(E)I.C.U./H.D.U. FACILITIES

1. I.C.U./H.D.U. facilities :

Present

Not present

2. No. of I.C.U. and H.D.U. beds :

3.Trained Nurses:

Trained Technicians :

4. Name of equipment in I.C.U. :

Sl No

Name of equipment

Sl No

Name of equipment

(F) OTHER SUPPORTIVE FACILITIES

Data about facilities available in the hospital :

(G) LABORATORY FACILITIES

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

SL No

Name

Designation

SL No

Name

Designation

2. No. of temporary staff members with their designations :

Sl No

Name

Designation

Sl No

Name

Designation

3. Names of the investigations carried out in the Department :

Name of the Insvestigation:

4. Name and No. of Equipments available :

Sl No

Name

Designation

Sl No

Name

Designation

(H) IMAGING SERVICES

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

Sl No

Name

Designation

Sl No

Name

Designation

2. No. of temporary staff members with their designation :

Sl no

Name

Designation

Sl no

Name

Designation

3. Names of the investigations carried out in the Department :

Name of Investigation

4. Name and No. of Equipments available :

Sl No

Name

Equipment

Sl No

Name

Equipment

(I) HAEMATOLOGY SERVICES :

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

Sl no

Name

Designation

Sl no

Name

Designation

2. No. of temporary staff members with their designation :

Sl no

Name

Designation

Sl no

Name

Designation

3. Names of the investigations carried out in the Department :

Name of Investigation

4. Name and No. of equipments available :

Sl no

Name

Equipment

Sl no

Name

Equipment

(J) BLOOD BANK FACILITIES :

(K) DIALYSIS FACILITIES :

(L) OTHER SUPORTIVE EXPERT PERSONNEL :

Sl No

Name of Expert Personnel

Designation

Sl No

Name of Expert Personnel

Designation

Date *

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Place *

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