The Transplantation of Human Organs Rules, 1995 - Form 11

FORM 11

APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY OUT ORGAN TRANSPLANTATION

To

(A) 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. Annual budget :

9. Patient turn-over/year : 

(B) SURGICAL TEAM :

1. No.of beds:

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 designation:

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

4. Patient turnover per year:

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

(D) ANAESTHESIOLOGY

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

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 I.C.U beds .................................................................

3.Trained
Nurses .................................................

Technicians ..........................................

(F) OTHER SUPPORTIVE FACILITIES

Data about facilities available in hospital.

(G) LABORATORY FACILITIES :

No. of permanent staff with their designations

No. of temporary staff with their designations

Names of the investigations carried out in the Dept

Name and number 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 Dept

4. Name and number 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 Dept

4. Name and number of equipments available

(J) BLOOD BANK FACILITIES: Yes........................... No....................

(K) DIALYSIS FACILITIES Yes........................... No.................…

(L) OTHER PERSONNEL

Neurologist                  Yes/No

Neuro-Surgeon            Yes/No

Urologist                      Yes/No

G.I. Surgeon                Yes/No

Paediatrician                Yes/No

Physiotherapist            Yes/No

Social Worker               Yes/No

Immunologists              Yes/No

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 authorised personnel. A Bank Draft/Cheque of Rs. 1,000/- is being enclosed.
sd/-

HEAD OF THE INSTITUTION