STANDARD ASSESSMENT FORM FOR PG COURSESYEAR 2019-20

(Report in this SAF prescribed for the year 2019-20 will only be accepted)
SUBJECT –OPHTHALMOLOGY
INSTRUCTIONS TO DEANS & ASSESSORS

1. Please read the SAF carefully before filling it up. Retrospective changes in Data will not be
allowed.

2. Do not use Annexures. All information should be provided in SAF at appropriate place
earmarked. No Annexures will be considered.

3. Experience details should be supported by experience certificate from competent authority

(from the place of work) without which it will not be considered.

4. Don’t add, alter or delete any column of SAF.

5. In case of DNB qualification name of the hospital/institution from where DNB training was
done and year of passing must be provided. Simply saying National Board of Examination,
New Delhi is not enough. Without these details DNB qualification holder will be summarily
rejected.

6. Experience of defence service must be supported by certificate from the competent authority
of the office of DGAFMS without which it will not be considered.

7. Dean will be responsible for filling all columns and signing at appropriate places.

8. If promotion is after cut-off date (i.e. after 21/07/2013 for Professor & 21/07/2014 for
Associate Professor) or benefit of publications is given in promotion before cut-off date, give
the list of publications immediately below the name of faculty in this format: Title of Paper,
Authors, Citation of Journal, details of Indexing. Photocopies of published articles should also
be submitted without which they will not be considered. Give details of only original research
articles; Case reports, Review articles and Abstracts will not be considered and should not be
included.

9. No abbreviations of the name of Medical College in the Faculty List and Declaration Forms
are acceptable

INSTRUCTIONS TO ASSESSORS: Please ensure that only original research papers

published in indexed print journals are included in the list. Remaining entries, if included,
should be struck off.

10. Assessor may give any relevant remarks not shown in the assessment report on the page
marked “Remarks of Assessor”. No separate confidential letter should be sent.

11. Count only those faculty & Residents who have signed in attendance sheet before 11:00 a.m.
and are present for subsequent verification and are found eligible on verification and also
those who are on MCI permitted leave and MCI or Court duty. Do not forget to obtain
signature of faculty and residents/senior residents in faculty table in appropriate column .
 STANDARD ASSESSMENT FORM FOR POSTGRADUATE COURSES
(OPHTHALMOLOGY)

1. Name of Institution:________________________________________________________________
MCI Reference No.: ________________________________________________________________
2. Particulars of the Assessor:- Assessment Date_______________________

Name …………………………………………. Residential Address (with Pin Code)

Designation…………………………………… ……………………………………………...….
Specialty………………………………………. ………………………………………………....
Name & Address of Institute/College Phone .(Off) ……………(Resi.) …………….
……………..………………………………….. (Fax)…………………………………………...
…………………………………………………. Mobile No. ……………………………………
…………………………. E-mail: ………………………………………...
……………………….
3. (Institutional Information)

A). Particulars of college

Item College Chairman/ Director/ Medical
Health Secretary Dean/ Principal Superintendent
Name

Address

State
Pin Code
Phone
(Off)
(Res)
(Fax)
Mobile No.
E.mail:

B). Particulars of Affiliated University

Item University Vice Chancellor Registrar

Name

Address

State
Pin Code
Phone
(Off)
(Res)
(Fax)
Mobile No.

E.mail:
 SUMMARY

Date of Assessment:________________ Name of Assessor:_______________________

1. Name of Institution Director / Dean / Principal

(Private / Government) (Who so ever is Head of Institution)
Name
Age & Date of Birth
Teaching experience
PG Degree
(Recognized/Non-R)
Subject

2. Department inspected Head of Department

Name
Age & Date of Birth
Teaching experience
PG Degree
(Recognized/Non-R)

3. (a). Number of UG seats Recognised Permitted First LOP

(Year: ) (Year: ) date when
MBBS course
was first
permitted

(b). Date of last inspection UG PG

for Purpose: Purpose:
Result: Result:

4. Total Teachers available in the Department:

Designation Number Name Total Benefit of

Teaching Publications
Experience in
Promotion
Professor
Addl./Assoc Professor
Asstt. Professor
Senior Resident

5. Number of Units with beds in each unit:

6. Clinical workload of the Institution and Department concerned :

Parameter Entire Hospital Department of Ophthalmology

On the Day of On the Day of Average of 3

Assessment Assessment Days Random
OPD attendance upto 2 p.m.
New admissions
Total Beds occupied at 10 a.m.
Total Required Beds
Bed Occupancy at 10 a.m. (%)
Major Operations
Minor Operations
Day Care Operations
Total Number of Deliveries
Total Caesarean Sections
Total Deaths
Casualty attendance
Put N.A. whichever is not applicable to the Department.

Note:
 OPD attendance is to be considered only upto 2 p.m. Bed occupancy is to be considered at 10 a.m. only.
 Investigative Data to be verified with Physical Registers in Radiodiagnosis & Central Clinical Laboratory.
 Data to be verified with Physical Registers in Blood Bank.

7. Investigative Workload of entire hospital and Department Concerned.

Parameter Entire Department of Ophthalmology

Hospital
On the Day of On the Day of Average of 3
Assessment Inspection Random Days
Radio-diagnosis MRI
CT
USG
Plain X-rays
IVP/Barium etc
Mammography
DSA
CT guided FNAC
USG guided FNAC
Any other
Pathology Histopath
FNAC
Hematology
Others
Bio-Chemistry
Microbiology
Blood Units Consumed
8. Year-wise available clinical materials (during previous 3 years) for department of Ophthalmology

S.No. Parameters Year 1 Year 2 Year 3

(Last Year )
1 Total number of patients in OPD
2 Total number of patients admitted (IPD)
3 Total Number of Major Operations
4 Total Number of Minor Operations
5 Total Number of Day Care Operations
6 Total Number of Normal Deliveries
7 Total Number of Operative Deliveries
8 Total Number of Caesarians
Note : Put N.A. for those coloumns not applicable to the department

9. Publications from the department during last 3 years:

(Give only full articles published in indexed journals. No case reports or review articles be given)

10 Blood Bank License valid Yes / NO(enclose copy)

Blood component facility available Yes / NO(enclose copy)
Number of blood units stored on the inspection day
Average units consumed daily (entire hospital)

11. Specialized services provided by the department: Adequate / not adequate

12. Specialized Intensive care services provided by the Dept: Adequate / not adequate
13. Specialized equipment available in the department: Adequate / Inadequate
14. Space (OPD, IPD, Offices, Teaching areas) Adequate / Inadequate

15 Library Central Departmental

Number of Books
Number of Journals
Latest journals available upto
16. Casualty Number of Beds_______Available equipment ____Adequate / Inadequate

17. Common Facilities

 Central supply of Oxygen / Suction: Available / Not available
 Central Sterilization Department Adequate / Not adequate
 Laundry: Manual/Mechanical/Outsourced:
 Kitchen Gas / Fire
 Incinerator: Functional / Non functional Capacity: Outsourced
 Bio-waste disposal Outsourced / any other method
 Generator facility Available / Not available
 Medical Record Section: Computerized / Non computerized
 ICD10 classification Used / Not used
 Total number of OPD, IPD and Deaths in the Institution and department concerned during the last one
year:

In the entire hospital In the department of Ophthalmology

OPD OPD
IPD (Total Number of IPD (Total Number of
Patients admitted) Patients admitted)
Deaths Deaths

19. Number of Births in the Hospital during the last one year:

Note : 1) The data be verified by checking the death/birth registration forms sent by the college/hospital to the
Registrar, Deaths & Births (Photocopy of all such forms be provided.)
: 2) Year means calendar year (1st January to 31stDecember)

20. Accommodation for staff Available / Not available

Hostel UG PG Interns
Accommodation

Boys Girls Boys Girls Boys Girls

No. of Students
No. of Rooms
Status of Cleanliness

21 Total number of PG seats Recognized Date of Permitted Seats Date of

in the concerned subject - seats recognition permission
Ophthalmology Degree
Diploma

22. Year wise PG students admitted (in the department inspected) during the last 5 years and available
PG teachers

Year No. of PG students admitted No. of PG Teachers available in the dept.

Degree Diploma (give names)
2016
2015
2014
2013
2012

23 Other PG courses run by Course Name No. of seats Department

the institution DNB
M.Sc.
 Others

24. Stipend paid to the PG students, year-wise:

Year Stipend paid in Govt. colleges by State Govt. Stipend paid by the Institution
Ist Year
IInd Year
IIIrd Year
IVth Year

25. List of Departmental Faculty joining and leaving after last inspection:

DESIGNATIONS NUMBER NAMES

JOINING FACULTY LEAVING FACULTY
Professor
Associate Prof.
Assistant Prof.
SR/Tutor/Demons.
Others

26. Whether other medical super specialty department exits in the institution …………… Yes/No
(If yes give details)

Name of Beds/Units When LOP for DM seats Available faculty

department granted & Number of seats (Names & Designation)

I have physically verified the beds, faculty and patients of above Super specialty department and they
have not been counted in ophthalmology department inspection.

27. Faculty deficiency, if any

Designation Faculty available Faculty required Deficiency, if any

(number only)

Professor
Assoc Professor
Asstt. Professor
Sr. Residents
Jr. Residents
Tutor/ Demonstrator
Any Other
28. REMARKS OF ASSESSOR

1. please do not repeat information already provided

2. please do not make any recommendation regarding granting permission/recognition
3. if you have noticed or come across any irregularity during your assessment like fake or dummy faculty, fake or
dummy patients, fudging of data of clinical material etc., please mention them here)