PRESCRIBED APPLICATION FORMS PRICE = RS. 200/- APPLICATION FOR REGISTRATION / RENEWAL OF REGISTRATION UNDER SECTION 4 OF J&K NURSING HOMES AND CLINICAL ESTABLISHMENTS (REGISTRATION AND LICENSING) ACT, 1963 AMENDMENT 2006 S.NO. PARTICULARS DETAILS 1 Name of applicant 2. Residential address 3. Technical Qualification 4. Nationality of the Applicant 5. Locality of the registered society / association /corporate body/Company. 6. Name and other particulars of the Nursing Home in respect of which registration is applied for. 7. Place where Nursing Home is situated. 8. Brief description of the infrastructure and equipments of the Nursing Homes/Clinical establishments or any premises used in connection there with. (Submit copies of Building Plan alongwith permission from Competent authority) 9. Floor space per bed for the patient with total no. of beds. 10. Arrangements for Medical check-up and immunization of employees. 11. Floor space of service and utility areas like kitchen, canteen and Landry etc. 12. Details of arrangement made for public convenience alongwith total number of such units. 13. Details of arrangement made for storage and service of food. 14. No. of beds speciality-wise 15. Name with age and qualification of Members of the Nursing Staff. 16. Place where Nursing Staff is accommodated. (Give full address and details) 17. Name with age and qualification of the Resident or the visiting Physician/Surgeon in the Nursing Homes (Copies of the certificates duly attested and permission from the Competent authority in respect of Govt. doctors/Para-Medics.) 18. Whether the Nursing Home is under the supervision of qualified Hospital administrator/ practioner/ doctor. If so, his/her name and qualification alongwith the copies of the certificates. 19. Proportion of qualified and semi-skilled Nurses on the Nursing Staff 20. Whether any un-registered medical practioner or un-qualified midwife is employed for the Nursing Home 21. Whether any person of alien nationality is employed in the Nursing Home, if so, his name and other particulars. 22. Fee charges for patients (Category-wise for procedures/admissions/investigations etc. 23. Whether the applicant is involved in any other Nursing Home or Business, if so, the place where such place is situated. 24. If registered, No. & date of expiry of registration. 25. Whether ambulance is available in the Hospital ( indicate make, model, and registration No.) 26. List of equipments available in the Hospital.(Enclose copy of bills and detail specifications, make /model and Number). 27. Whether blood Bank/ transfusion /storage facilities are available, if not, whether register with some authorized blood bank. 28. Availability of Oxgeon and Nitrious Oxide Cylinders. 29. Details of arrangement of medicines/disposables and dressing /suturing material indicating sources and attach copies of the bills. 30. Arrangement for landry services for washing of linen. 31. Arrangement for heating/cooling system ( Give details) 32. Indicate arrangement for Electricity supply alternate source, stand by Generators and their capacity. 33. Indicate arrangement for water supply, alternate source and total storage capacity. 34. Indicate arrangement for disposal of Bio-Medial Waste ( enclose copy of authorization from J&K State Pollution Control Board). 35. Indicate communication facilities (Telephone, fax, inter-net etc.) 36. Whether arrangement for medical record keeping, retrieval of records has been made. UNDERTAKING I solemnly declare that above statements are true to the best of my knowledge and belief. Nothing has been cancelled and in case of any false statement, I will be liable for action under rules. APPLICANT Dated:____________ Note: - In case the application is made on behalf of a Company, society, association or any other Corporate body, the name and the residential address of the person incharge of the management of such company/society should be given. This item is applicable only when the application is made on the behalf of a company/society/association or any other corporate body. The application should have following enclosures: 1. Building Plan and details thereof. 2. Permission of Building plan from the competent authority. 3. Registration certificate from Industries Department/Labour Department. 4. List of equipments with specification, Number, model and make. 5. List of manpower alongwith their attested copies of their qualification/Technical certificates. 6. Para-medics working in the Hospital shall have passed the diploma from SMF or any other recognized institute. In case of doctors a degree recognized by MCI. 7. Details of full time Resident Medical Officers and other staff. 8. Name /Bank with whom the accounts are maintained. 9. Authorization from J&K State Pollution Control Board. 10. Source of purchase of medicines/dressing/disposables/sutures material/oxygen and nitrous oxide re-filling. 11. In case visiting specialists/doctors/para-medics working in the Nursing Homes are in Govt. Service, the copy of permission from appointing authority be also enclosed. 12. Original receipt of fee deposited in the Government Treasury under Acctt. Head No. 0210-Medical to be enclosed. 13. In case of X-Ray Clinics, the Radiological safety measures as per BRAC to be ensured and details provided.
