Proposal for academic year

20___ - 20___

Maharashtra University of Health Sciences, Nashik

Application for starting of Certificate Course viz.
“Modern Midlevel Service Provider”
The Govt. Hospital / Health and Wellness Centre seeking permission to Start Certificate
Course viz. “Modern Midlevel Service Provider” shall submit the application in
Two copies in the prescribed format to the Registrar, Maharashtra University of Health
Sciences, Nashik – 422 004, along with prescribed fees total Fees Rs. 1,40,000/-.
(Rs. 1,00,000/- for Govt. Hospital / Health and Wellness Centre Recognition and
Rs. 40,000/- for Starting Certificate Course)

To,
The Registrar
Maharashtra University of Health Sciences,
Mhasrul, Dindori Road,
Nashik – 422 004.

Sir,
I am / we are submitting herewith the application with a request, under Section 64 of
the Maharashtra University of Health Sciences Act, 1998 for starting “Modern Midlevel
Service Provider” certificate course for 60/30 Intake, for Academic Year 2019 – 20.
(Govt. Hospital / Health and Wellness Centre having minimum 200 beds for 60 intake
capacity and 100 beds 30 Intake Capacity.)

1) Name and address of the Hospital:

___________________________________________________________________
___________________________________________________________________
________________________________ PIN code : ________________________
Phone No. (O) : __________________________________________________
Email Address: __________________________________________________
2) Name of Civil Surgeon / Medical Superintendent :__________________________
Phone No. _____________________, Mobile No._________________________
3) Name of Co-odinator :_______________________________________________
Phone No. _____________________, Mobile No._________________________
4) Payment details :
i) Amount Rs.1,40,000/-
(Rs. 1,00,000/- for Hospital Recognition and Rs. 40,000/- for Starting Certificate Course)
ii) Mode of Payment RTGS / NEFT /DD/ Pay Online _________________________
iii) DD / UTR / Reference No. & Date : _____________________________________
iv) Name of the Bank and Branch:(Please attach receipt incase the fees paid by
RTGS/NEFT/Pay Online)

Sign of Civil Surgeon / Medical Superintendantant

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5) Auditorium : Available / Not Available

6) Demonstration Room : Available / Not Available

7) Library cum Seminar Room :

i) Minimum Seating Capacity 50 Available / Not Available
ii) National Health programme guidelines Available / Not Available
and standard treatment protocol

8) Coordinator Office : Available / Not Available

9) Govt. / Rented Guest House: Available / Not Available
10) Minimum OPD chamber :
Facility with minimum 100/200 beds & 8 OPD Chambers: Available / Not Available

11) Bed Strength minimum 100/200 Beds: Available / Not Available

12) Instruments and equipment :

Sr. Instrument No. of Available /
No. Units Not Available
1 BP apparatus
2 Adult weighing machine
3 Facility for blood sugar estimation
4 Facility for HBA1c
5 Glucometer
Facility for urine examination for sugar, ketone
6
bodies
7 Ophthalmoscope
8 Lumbar puncture needles (disposable)
9 Light Microscope
10 Haemoglobinometer
11 Centrifuge Machine
12 X-ray viewing box
13 Overhead projector
14 Slide Projector
15 Proctoscope
16 Non-invasive B.P.Apparatus
17 Pulse oximeter
18 Ambu bag
19 Laryngoscope
20 ECG Machine

Sign of Civil Surgeon / Medical Superintendantant

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13) Teaching faculty :
All Post Graduate Doctors of District Hospital will be Mentor / Teachers.
Sr. No. Department No. of scpeialist Available / Not Available
1 Medicine 1
2 Surgery / Orthopedics 1
3 Obstetrics and gynecology 1
4 Pediatric 1
5 Dentistry 1
6 Public Health Specialist 1
7 ENT 1
8 Opthalmic 1

14) Clinical material:

i) OPD: Average per day – 200 patients Available / Not Available
ii) IPD: Average bed occupancy in ward: 50% Available / Not Available

15) Computer Lab with Internet facility: Min. 5 computers: Available / Not Available

16) Ambulance: Available / Not Available

17) Operation Theaters: (minmum-2) Available / Not Available

18) Other investigation facilities:

X-ray Available / Not Available
USG Available / Not Available

19) Laboratory: Available / Not Available

(Well-equipped laboratory facility for
all types of pathological investigations)

20) Blood Bank / Blood Storage Unit: Available / Not Available

21) Causality Department: Available / Not Available

22) Other Facility :

i) Telephone Available / Not Available
ii) E-mail Available / Not Available
iii) Photocopy Machine Available / Not Available

Place: ……………… Sign of Civil Surgeon / Medical Superintendantant

Date: ………………… Seal of the Hospital

Note:- 1. Every page of the application must be serially numbered.

2. Please note that incomplete application form will not be accepted.

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