THE TRANSPLANTATION OF HUMAN ORGANS ACT, 1994
(Central Act 42 0f 1994)

FORM 11
APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY OUT ORGAN TRANSPLANTATION
To

The Appropriate Authority for organ transplantation ..............................
(State of Union Territory) We hereby apply to be recognised as an institution to carry out organs transplantation. The required data about the facilities available in the hospital are as follows:-
(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                        ..................................................................
4.      Name and number of equipments in ICU
(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

Nephorlogist Yes/No
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