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Bombay Nursing Homes Association

Reg. No. : P.T.R. No. F-4517 (Bom.)

FORM A
 Form for Application of Registration

 1. Name of Nursing Home :

 

 2. Address of Nursing Home :

 

 3. Phone Numbers :

 

 4. Name of applicant :
(Person directly responsible for the management of the nursing home)

 

 5. Qualification of the applicant :

  

 6. Address of applicant :

  

 7. Phone number :

  

 8. Nationality of applicant :

 

 9. Nature of firm : (Please Tick)

 Ownership ( )

 Partnership ( )

 Registered Company ( )

 Voluntary Organization ( )

 Society ( )

 Body/Trust ( )

 10. Type of Nursing home: (Please tick)

 Maternity home with OT ( )

 Maternity home without OT ( )

 Surgical Nursing home ( )

 General Nursing Home ( )

 Other (please specify)

 

 11. Premises :

 Whether construction approved by authority :

 Yes / No

 Whether owned by the applicant :

 Yes / No (submit the copy of the deed, if any)

 Whether rented :

 Yes / No (submit up to date rent receipt, if yes)

 Whether registration :

 Yes / No ( submit lease - deed with N.O.C)

 Reception counter :

 Yes / No

 Waiting room :

 Yes / No

 Ventilation :

 Whether sufficient

 Lighting :

 Whether sufficient

 Drinking water supply :

 Source :

 Piped water supply ( ) Underground ( ) Others ( )

 Quantity :

 Adequate /Inadequate

 Quality :

 Satisfactory / Unsatisfactory

 Cooling Arrangement :

 Provided / Not provided

 12. Trade license :

 Name of authority : ( )
 License No : ( )
 Date of issue : ( )

 13. Clearance from Pollution Control Board :

 Yes / No / Applied For

 14. Clinical waste disposal license :
(From Panchayat/Municipality/Municipal Corporation)

  Yes / No / Applied For

 15. Exemptions granted from :

 Custom duty Yes / No / Applied For

 16. Registers: (To be maintained) :

 Staff register : (Name / Address/ Qualification of all)

 Present / Will be provided

 Attendance Register :

 Present / Will be provided

 Stock register : (Including stock of life saving drugs)

 Present / Will be provided

 Cash book register :

 Present / Will be provided

 Admission register :

 Present / Will be provided

 Inspection book :

 Present / Will be provided

 17. Whether training of medical or paramedical course are / will be given :

 Yes / No

 18. If yes, whether approved by state medical council/government of Maharashtra :

 Yes / No

 19. Sanitary arrangement :

 Drainage system :

 Covered / uncovered

 Water closets Number :

 For male ( ) For Female ( )

 Lavatory Number :

 For male ( ) For Female ( )

 System of garbage disposal :

 own arrangement / other ( please specify)

 20. Electricity supply source :

 Generator ( )

 Government Supply ( )

 Both ( )

 21. Total no of beds :

 

 22. Space of each patient :

 _________ Sq.feet

 23. Total number of wards :

 General: ____________

 Special:________________

 24. Space of each patient in the ward :

 ________Sq.feet

 25. Number of cabins :

 

 26. Number of cubical :

 

 27. Staff :

 

 28. Total number of staff :

 

 29. Number of permanent staff :

 

 30. Number of temporary staff :

 

 Category of staff

 Name

 Qualification

 Registration No.

 Name of the Faculty

 Nature of service(Temp/perm.)

 Consultants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Office staff

 

 

 

 

 

 

 

 

 

 

 RMO

 

 

 

 

 

 

 

 

 

 

 Matron

 

 

 

 

 

 

 

 

 

 

 Nursing Staff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Female attendant

 

 

 

 

 

 

 

 

 

 

 Other staff

 

 

 

 

 

 

 

 

 

 

 31. In case the Nursing home also provides for diagnostic facilities :

 Pathology laboratory/X-ray facility/ECG/EEG/CT Scan/USG/MRI/Others (please tick)


 Category of staff

 Name

 Qualification

 Registration No.

 Name of the Faculty

 Nature of service(Temp/perm.)

 Medical officer

 

 

 

 

 

 

 

 

 

 

 Lab Technician

 

 

 

 

 

 

 

 

 

 

 Female attendant

 

 

 

 

 

 

 

 

 

 

 Other Staff

 

 

 

 

 

 

 

 

 

 
Bombay Nursing Homes Association