GUJARAT NURSING COUNCIL COUNCIL HOUSE, OPP. MANIBEN AYURVEDIC GOVT. HOSPITAL, CIVIL HOSPITAL CAMPUS, ASARWA, AHMEDABAD

GUJARAT NURSING COUNCIL COUNCIL HOUSE, OPP. MANIBEN AYURVEDIC GOVT. HOSPITAL, CIVIL HOSPITAL CAMPUS, ASARWA, AHMEDABAD 380 016. PROFORMA TO PROVIDE INFORMATION AT PERIODICAL/ ANNUAL INSPECTION (Two Copies of Completely Filled Performa be handed over to the inspectors on their arrival) Programme under Inspection : 1. Basic B.Sc (N) 2. M.Sc (N) 3. Diploma in General Nursing & Midwifery GENERAL INFORMATION 1. Name of the Institution: 2. Full Address with pin code: Telephone Numbers of the Institution Principal office: Resi.: Mobile Fax: E_mail: 3. Year of Starting: 4. Administrative Control:* 1. Government 2. University 3. Municipal Corporation 4. Mission/Society 5. Private /Public Trust 6. Army Full Address of Controlling Authority : * Attach the copy of organization chart Page 1

5. Number of seats sanctioned. Sr. Course No. 1 Diploma in G.N.M. 2 B.Sc. (N) 3 M.Sc (N) Seats G.N.C. I.N.C. University 6. Students under training in each of the nursing education course. Course I Year II Year III Year IV Year G.N.M. B.Sc (N) M.Sc (N) Any other Total Total 7. Mention the date of last inspection for each Course: (Attach copy of last inspection report) (Annexure no. ) Council / University G.N.M B.Sc (N) M.Sc (N) State Nursing Council Indian Nursing Council University Page 2

PART-I AREA OF THE INSTITUTION AND TEACHING FACILITIES. I.1 Total Land in acres/sq. Mts. : I.2. School / College Building Separate teaching block : 1. Yes 2. No Built-up area of teaching block sq. Mts. Is the institution 1. Owned 2. Rented/Leased If owned, proof of ownership of building be enclosed. (Annexure no. ) If leased - copy of lease/rent contract be enclosed. (Annexure no. ) - Period of lease contract Does all the courses mentioned under item no.6 are imparted in this building? 1. Yes 2. No I.3. Physical facilities of Scholl/ College Building * Class room/ Hall Facilities Size of room Number of L x W Tables/Beds Chairs Storage Cupboard Remarks Lecture Hall 1. 2. 3. 4. 5. Laboratories 1. Fundamentals 2.C.H. Nursing 3. M.C. Health 4. Nutrition 5.Computer Lab Exam Hall Auditorium Counseling room Common room Page 3

I.3. Continue.. Office rooms for Size L x W Telephone Facility Computer Facility Remarks 1. Principal 2. Vice Principal 3. Associate Professor 4. Lecturer 5. Tutors/Clinical instructors 6. Clerical staff 7. Personal Assistant 8. Accountant Library Facilities * 1. Books room size (L x W) 2. Reading room size (L x W) 3. Journal/ Magazine room size(l x W) 4. No. of chair and table 5. Total No. of Books (Attach the list) (Annexure No. ) 6. Purchase of latest addition in last three years 7. No. of journals subscribed Indian foreign (Attach the list Annexure No. ) 8. No. of books circulated last year 9. Photocopier facilities Available / Not Available 10. Internet Facilities Available / Not Available Other Facilities 1. Store Yes/ No 2. Record room Yes/.No 3. Duplicate/ Xerox room 4. A.V. Aids room 5. Drinking water Satisfactory / Not Satisfactory 6. Toilet ladies Satisfactory / Not Satisfactory - Gents Satisfactory / Not Satisfactory 7. A.V.Aids - numbers in working condition (Attach the list) (Annexure no. ) 8. Transport facilities : - Jeep/ Minibus/Bus/Car Controlled by: - Principal / Transport manager / Superintendent/ Other 9. Staff quarters: - Yes No Mention category wise list (Annexure no. ) * Attach copy of floor plan of building. (Annexure No ) Page 4

I.4 Hostel Facilities 1. Separate hostel building Yes No If no combined with School/ Shared with 2. Hostel buildings - Owned Rented/Leased If owned proof of ownership of building be enclosed Annexure no. If leased - copy of lease/rent be enclosed (Annexure no. ) Period of lease contract 3. Built up area of hostel Sq. Mts. Girls Boys 4. Hostel facilities for.. 5. No. of rooms for.. 6. No. of students in each room... 7. Area of each room.... 8. No. of bathrooms.. 9. No. of Toilets. 10. No. of students Staying in the hostel.. 11. Whether the hostel has provisions for a. Water Supply round the clock h. Pantry b. Fans, light with Cooling facility i. Visitor room c. Safe disposal of wastes j. Recreation room d. Laundry/Ironing room k. Sick room e. Hot water supply l. Guest Room f. Indoor game facility g. Safe drinking water Page 5

12. Room furniture allotted to each student Bed Table chair Cupboard 13. Provision for recreation room with TV, Radio, DVD, Public address system:. 14. Facilities for Indoor games 15. Facilities for Outdoor games 16. Mess Facilities a. Dinning room Size Seating capacity (in no.) b. Hand Washing Facility Furniture: Table Chair c. Safe drinking water facility d. Refrigerator 17. Kitchen Facilities a. Cooking Platform b. Fuel (LPG/Kerosene oil/coal/fire woods) Specify c. Cooked food storage facilities (Specify) d. Raw material storage facilities (Specify) 18. Warden s residence adjoining to hostel:. Page 6

I.5 Teaching Faculty (full Time) number of posts. Sr. No Category Sanctioned Filled If teaching in other course - mention the name of course. 1 Principal Remarks 2 Vice Principal 3 Associate Prof./ Readers 4 Lecturers 5 Tutors/Clinical Instructors 6 Any other (specify) TOTAL Page - 7

I.6 Teaching Faculty Profile (FULL TIME) Sr No Designation 1 Principal/Head of the Institution 2 Vice Principal Name and Date of Birth R.N.R.M. No(*) Post basic(*) and/or P.G. Qualification Specialty Area Name of institution, University and year of passing DT of Joining 3 Associate Professor 4 Lecturer * Attach copy of Registration certificates, Degree/ Diploma Certificate and Mark sheets. Page - 8

I.6 Continue Sr No Designation 5 Tutor / Clinical Instructor Name and Date of Birth R.N.R.M. No(*) Post basic(*) and/or P.G. Qualification Specialty Area Name of institution, University and year of passing DT of Joining * Attach copy of Registration certificates, Degree/ Diploma Certificate and Mark sheets. Page 9

I.7 Particular of External Teachers Sr. No. 1 Name Qualification Teaching Experience Subject teaching Numbers of Hours Per year Remarks 2 3 4 5 6 7 8 9 Page - 10

I.8 Office Staff Sr. No. Designation Sanctioned No. in position Date of Joining Remarks 1 Administrative Officer 2 Accountant/Cashier 3 U.D.C. 4 L.D.C. 5 Librarians 6 Computer Programmer 7 Library Attendant 8 Laboratory Attendant 9 Driver 10 Peon/Office Attendant 11 Watch Man 12 Cleaner 13 Sweeper I.9 Hostel Staff Sr. No. Designation Sanctioned No. in position 1 Warden 2 House Keeper/ Assistant Warden 3 Cooks 4 Bearer/Helper 5 Watch Man 6 Peon/ Ayah 7 Sweeper 8 Mali/ Gardner 9 Washer man (Dhobi) Date of Joining Remarks Page 11

I.10 Budget 1. Separate budget allotted 1. Yes 2. No 2. Name and designations of the controlling authority : 3. Name and designations of the drawing and disbursing authority : 4. Mention the last year s expenditure. Sr.No. Particulars Expenditure * 1 Salary of Teaching Faculty 2 Salary of Non teaching staff 3 Salary of hostel staff 4 Stipend for students (If applicable) 5 New Equipment and its maintenance 6 Linen and other house hold supplies 7 Maintenance of vehicle and cost of petrol/diesel 8 Purchasing/Maintenance of furniture 9 Office expenditure including stationery and postage 10 The library-purchase of books, 11 Journals, daily newspapers, and other expenditure 12 Purchase of A.V. aids and Other teaching materials 13 External Lecturers payment 14 T.A. & D.A. Paid to nursing tutors 15 Contingencies 16 17 18 19 20 TOTAL * Please attach last financial year s Audited income and expenditure statement of the Trust /Association and of the institution. Annexure no. Page 12

PART - II CLINICAL FACILITIES II-1. Hospital Facility Parent Hospital Yes No If yes, give following information: Name and Address No. of beds (Total Capacity) Average occupancy (Taken from last 6 months) Distance from School/ College No. of schools /College affiliated II.2 Number of Affiliated Hospital(s). If yes, furnish the following details of each affiliated Hospital* Sr.No. Name and Address No. of beds (Total Capacity) 1. Average occupancy (Taken from last 6 months) Distance from School/ College No. of schools /College affiliated 2. 3. 4. 5. * Maintain these serial numbers while giving information related to affiliated hospitals and attach copy of M.O.U with hospitals. Page 13

II.3 Nursing Staff in the Hospital. * Hospital Parent Hospital Nursing Superintendent. Dy. Nursing Superintendent Head Nurse Staff Nurse Sanct. Filled Sanct. Filled Sanct Filled Sanct Filled Remarks Affiliated 1. Affiliated 2. Affiliated 3. Affiliated 4. Affiliated 5. Total * attach the list with name of nursing council and registration numbers in case of non Governmental and non Municipal corporations hospitals. Page - 14

II.4 Beds Distribution in Clinical Areas Clinical Areas No. of Beds Average Occupancy No. of Ward Sisters No. of Staff Nurses Prt. Hosp. Aff. Hosp. Prt. Hosp. Aff. Hosp. Prt. Hosp Aff. Hosp. Prt. Hosp Aff. Hosp. General Surgical Orthopedic E.N.T. Opthalmic Neuro surgery Cardio therasic Oncology Surgical General Medical Neurology Cardiology Isolation Ward Medical Oncology Antenatal Ward Postnatal Ward Gynec/Obst. Ward Septic Ward Pediatric Medical Pediatric Surgical Emergency/Trauma NICU & IPCU ICU & ICCU Post Operative Others TOTAL * M Morning Shift, E- Evening Shift, N- Night Shift M* E* N* M* E* N* M* E* N* M* E* N* Page 15

II.5 Other Clinical Area OPERATION THEATRES 1. General O. T. 2. Orhtopaedic O.T. 3. Gynaec & L.R. O.T. 4. Opthalmic O.T. 5. ENT O.T. 6. Minor O.T. 7. Any other O.T. Parent Affiliated Hospitals Hospitals 1 2 3 4 5 Tab* Oprt^ Tab* Oprt^ Tab* Oprt^ Tab* Oprt^ Tab Oprt^ Tab* Oprt^ Remarks *- No. of Operation Tables ^ - No. of operations performed in last year II.6 Labour Room Facilities LABOUR ROOM 1. No. of labour tables 2. No. of deliveries in last year a)total b) Normal c) Abnormal 3. Separate Receiving room 4. Eclampsia room 5. Baby area / Corner 6. Attached Toilet Parent Affiliated Hospitals Hospital 1 2 3 4 5 Remarks Page 16

II.7 Out Patient Department O.P.D. 1. Average attendance per day Parent Affiliated Hospitals Hospital 1 2 3 4 5 Remarks 2. Injection room 3. Dressing room 4. Name of special clinics (If any) Page - 17

II.8 Community Health Facilities RURAL FIELD a. Name and Address of CHC/PHC area i) Adopted ii) Affiliated iii) Own Attach copy of permission letter from the Community health authority. Annexure b. Residential Accommodation available for : i) Supervising Teacher Yes No ii) Students Yes No If no, how arranged c. Details of CHC/PHC/SC Distance from the Institution i) Administered by: State Govt. /Panchayat/Others (Specify) ii) Area of coverage (in kms.) iii) Number of villages covered iii) Population Served iv) Field staff teaching responsibility Yes No v) Supervision of Students : i) Field Staff only ii) Teaching faculty only iii)both iv) Staffing Pattern (specify) v) Services Rendered Page - 18

B. URBAN FIELD a) Name and Address of the MCH & F.W.Centre i) Adopted ii) Affiliated iii) Own Attach copy of permission letter from the appropriate authority. Annexure b) Details of MCH & F.W. Centre Distance from the Institution i) Administered by : State Govt. /Municipal Corporation/Others (Specify) * ii) Distance from the hostel (in kms) iii) Name of Areas covered (i.e. Ward Numbers) iv) Population Served v) Teaching responsibility shared Yes No by field staff vi) Supervision of Students : i) Field Staff only ii) Teaching faculty only iii)both vii) Services Rendered viii) Staffing Pattern (specify) * Attach the copy of permission by appropriate authority. Page - 19

PART-III Teaching learning Activities III.1 Curriculum planning 1. Copy of Indian Nursing Council syllabus Available Not Available 2. The Statement of philosophy * (Annexure No. ) 3. Graphics Rotation plan * (Annexure No. ) 4. Annual Plan of teaching learning Activities * (Annexure No. ) 5. Teaching System a) Full block b) Partial Block c) Study Day 6. Clinical Supervision a) Nursing Tutor b) Lecturer c) Clinical Supervisor d) Hospital Staff 7. School/ College Committees: Committees# Yes No Minutes Kept Admission Committee Curriculum Committee Library Committee Discipline Committee S.N.A. Unit Advisory Committee # Attach the list of members of committees.(annexure No. ) 8. Result of Examination - last Three years. 200-200 200-200 200-200 Years Appeared Pass % Appeared Pass % Appeared Pass % 1 st Year 2 nd Year 3 rd Year TOTAL * Attach the copies. Page: 20

III.2 Records maintained by institution Sr. No. Name of record Yes No 1 Admission Register 2 Students leave register 3 Health record of students 4 Clinical and field experience record 5 Cumulative record of each students 6 Practical Record - Procedure book - Midwifery case book 7 Co-curricular activities records 8 Hostel attendance register 9 Subj.: classroom attendance register 10 Clinical experience record 11 Internal Marks Register 12 Term test register 13 Unit test register 14 Council result register 15 Tutors daily attendance register 16 Leave record of staff 17 Affiliation records 18 Grant in Aid record 19 Vehicle log book 20 Inward and outward register 21 Staff conference/seminar attend. records 22 Stock and inventory records Page 21

III.3 Clinical Experience Sr. No. Clinical Area 1 Gen. Medical Ward- Male F.Y. Wks. or Hrs. S.Y. Wks. or Hrs. T.Y. Wks. or Hrs. Internship Wks. or Hrs. Total Wks. or Hrs. 2 Gen. Medical Ward- Female 3 Gen. Surgical Ward- Male 4 Gen. Surgical Ward- Female 5 Out patients department 6 Orthopedic ward 7 Burns Ward 8 Eye Ward + Eye OPD 9 E.N.T. ward + OPD 10 General OT 11 Neuro medical + Surgical wards 12 T.B. ward + OPD 13 Isolation ward 14 Intensive care units 15 Psychiatric ward + OPD 16 Pediatric ward + OPD 17 Gynec ward 18 Antenatal clinic 19 Antenatal ward 20 Labour room 21 Postnatal ward 22 P.P. Unit 23 Rural community health 24 Urban community health Page 22

III.4 Course of Instruction and Supervise Practice for DIPLOMA Programme. Year of Training / Subjects Anatomy & Physiology Microbiology Psychology Sociology Fundamentals of Nursing First Aid Personal Hygiene Community Health Nursing-I Environmental Hygiene H. Ed.& Comm. skills Nutrition English Medical Surgical Nursing I Medical Surgical Nursing II Mental Health & Psy. Nursing Computer Education Pharmacology Midwifery and Gynecology Community Health Nursing-II Pediatric Nursing Ed. Methods & Media for tg. Introduction to Research Profe. trends & Adjustment Admi. and Ward Management Health Economics No. of Hours Taken last year Following Available: Theory Practical Courses outline Lesson plan Page 23

III.5 Course of Instruction and Supervise Practice for COLLEGIATE Programme Year of Training / Subjects No. of Hours Following Available Given last year Theory Practical Course outline Lesson plan Anatomy Physiology Nutrition Biochemistry Nursing Foundations Psychology Microbiology Introduction to Computers English Library Work/ Self Study Sociology Pharmacology Pathology Genetics Medical Surgical Nursing - I Community Health Nursing I C. and E. Technology Library work/ Self Study Medical Surgical Nursing II Child Health Nursing Mental Health Nursing Library work/ Self study Midwifery and Ob. Nursing Community Health Nursing-II Nursing Research & Services Management TOTAL HOURS Page 24

III.6 Scheme of Examination (Applicable to COLLEGIATE Programme Only) Scheme of Examination followed by the University, Please write the marks. FIRST YEAR Subjects Internal External Total % for passing 1. Anatomy and Physiology 2. Nutrition and Biochemistry 3. Nursing Foundations 4. Psychology 5. Microbiology 6. English 7. Introduction to Computer Practical and Viva Voce 1. Nursing Foundations SECOND YEAR Subjects Internal External Total % for passing 1. Sociology 2. Medical Surgical Nursing I 3. Pharmacology, pathology, genetics 4. Community Health Nursing I 5. Communication & Ed. Technology Practical & Viva Voce 1. Medical Surgical Nursing I THIRD YEAR Subjects Internal External Total % for passing 1. Medical Surgical Nursing II 2. Child Health Nursing 3. Mental Health Nursing 4. Community Health Nursing I Practical & Viva Voce 1. Medical Surgical Nursing II 2. Child Health Nursing 3. Mental Health Nursing Page-25

FOURTH YEAR Subjects Internal External Total % for passing 1. Midwifery and Obstetrical Nursing 2. Community Health Nursing II 3. Nursing Research and Statistics 4. Mgt. of Nsg. Services & Education Practical & Viva Voce 1. Midwifery and Obstetrical Nursing 2. Community Health Nursing Attach copy of eligibility criteria for admission to examination: (Annexure No. ) Conduction of Practical Examination at: Clinical area Practical lab No. of students examined per day Examiners (Write the categories) System for supplementary examination: Describe - Enclose the ordinance and regulation of university regulating the collegiate nursing programme. (Annexure No. ) Page 26

PART IV IV.1 Strong points as per the Institutional Authorities: IV.2 Outstanding achievements and/or set back in last three years (if any). IV.3 Deficiencies (if any) as per the Institutional Authorities and plans to comply it. Signature. (Principal) Full name Date: Periodical Institutional Performa 210307 Page - 27