FORM 11

APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY

OUT ORGAN TRANSPLANTATION

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: -

1. Hospital

   1. Name …………………………………………

   2. Location………………………………………

   3. Govt. /Pvt……………………………………..

   4. Teaching/Non-teaching……………………….

   5. Approached by:

Road: Yes No

Rail: Yes No

Air: Yes No

6. Total bed strength: ………………………………………….

7. Name of the disciplines in the hospital………………………

8. Annualbudget ……………………………………………….

9. Patient turnover / year ……………………………………….

2. Surgical Team

   1. No. ofbeds ………………………………………………

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

   3. No. of temporary staff with their designations……………………..

   4. No. of operations done per year ……………………………………

   5. Trained persons available for transplantation

(Please specify organ for transplantation)

(C) Medical Team

1. No. of beds ……………………………………………

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

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

4. Patient turnover per year .……………………………………….….

5. No. of potential transplant candidates admitted per year. ………….

(D) Anaesthesiology

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

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

3. Name and No. of operations performed ……………………………….

4. Name and No. of equipments available ……………………………

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

6. No. of emergency operation theatres ………………………………

7. No. of separate transplant operation theatres ………………………

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

1. ICU/HDU facilities: Present …….... Not present……….

2. No. of ICU beds …………………..

3. Trained Nurses …………………..

Technicians …………………..

4. Name and number of equipments in ICU ………………….

(F) Other supportive Facilities

Data about facilities available in the hospital. ……………………

(G) Laboratory Facilities

1. No. of permanent staff with their designations. …………………….

2. No. of temporary staff with their designations. …………………….

3. Names of the investigations carried out in the Deptt. ………………….

4. Name and no of equipments available. …………………….

(H) Imaging Services

1. No. of permanent staff with their designations. …………………….

2. No. of temporary staff with their designations. …………………….

3. Names of the investigations carried out in the Deptt. ………………….

4. Name and no of equipments available. …………………….

(I) Haematology services

1. No. of permanent staff with their designations. …………………….

2. No. of temporary staff with their designations. …………………….

3. Names of the investigations carried out in the Deptt. ………………….

4. Name and no of equipments available. …………………….

(J) Blood Bank Facilities Yes …………. No …………

(K) Dialysis Facilities Yes. ………… No …………

(L) Other Personnel

1. Nephrologist Yes/No

2. Neurologist Yes/No

3. Neuro-Surgeon Yes/No

4. Urologist Yes/No

5. G.I. Surgeon Yes/No

6. Paediatrician Yes/No

7. Physiotherapist Yes/No

8. Social Worker Yes/No

9. Immunologists Yes/No

10. Cardiologist Yes/No

The above said information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorized personnel. A Bank Draft / Cheque of Rs. 1,000/- is being enclosed.

Head of the Institution