PART II ation for obtaining fresh affiliation or extension of affili: Appl State Medical Faculty of West Bengal for conducting Diploma in mi. in imi (Name of the Course(s)) 1. Name and address of the applicant:- uri Greater Lions Eye Hospital [As mentioned in Information Collection Form for the year - 2023 [Annexure-"B”) Address with Pin Code : 2” Mile, Sevoke Road, Behind Vishal Cinema Hall, Siliguri Phone No.(0353) 2543301. Fax No.(0353) 2545741. E-mail [email protected] Whether any other training course(s) are running by the Institute: Yes/No If yes, please indicate the name of other course(s): Ophthalmic Nursing 2. Status of the Institution: Charitabl Hospital, Licen Clinical Establishmen: Be 3. Details of the Institution: Details attached here with A. If it is Society/Trust Trust The Society Registration Act No. or the Trust No. under which the Society/Trustwas formed: (i) Registration No. Deed No 107/IV (ii) Date of Registration 04.06.1980 (iii) Place of Registration Siliguri (Attached copy of Registration of Society/Trust along with detail of constitution/Memorandum of Association of the Society/Trust) Copies are not required in case of existing Institutions. (iv) Details of member/Trustees and thelr experience in running Para Medical Courses alongwith present occupation and academic background: Name of the ] Designation in] Present ‘Academic Experience Member/Trustees Society Occupation Backgrou nd {Lion Binayamrit Mundra (Chairman [Business pprentect 2a Years (Dr. Rajive Kumar |Ophthalmologist [Sr. Eye Surgeon |MBBS, MD B Years (Dr. Arup Kumar Das [Medical Superintendent [6r. Eye Surgeon | MBBS, MS a vrs (Dr. Susmita Paul |Ophthalmologist I ‘ye Surgeon IMBBS, DNB A Years |r. Joshef Mollah lanager Operation(Unit2) Service ~|MOptom: ht7Vears | ____[atraining ———EB. If other, specify: i) Name and complete postal address of the Institution / Proposed Institute. Attached li) Name and address and Telephone No. of the authorized person for communication. Attached ili) Furnish the details of Resource and funding agencies. Attached iv) Number of students proposed to be admitted. 15 Nos v) Year of starting/proposed date of starting the course. September 2017 vi) Registration No. of the establishment for Practical Training. Attached Herewith 4. Details of Fire Safety Measures are as under : hed Herewi (Attach separate sheet) Alternative exit arranged or not. Yes Name of the authorized person to sign Registration forms, Admit Cards and other documents. Joshef Mollah 7. Attach Blood Bank Attendance Sheets of students in case of DMLT(Tech)Course. NA Note:~ a) b) °) dq) e) f) 9) Copy of updated license under Clinical Establishment Act of West Bengal be attached. In case of new Institution, or existing Institute will conduct new courses(s) copy of permission letter from the Government of West Bengal for conducting Para Medical Course be attached. In case of rented building of the institute, three years’ rental agreement with the owner of the premises be submitted with the Application Form for grant of recognition/extension of recognition be submitted, In case of existing affiliated Institute where no change of Building was made during the last 3 years submission ofrental agreement is not required. Copies of Blood Bank Facility (For DMLT [Tech] Course only) provided by Govt. Hospital / Private Blood Bank if any be attached. Incase of own Blood Bank, copy oflicense be attached. Remittance to the Affiliated Institute towards 1* year Course Fees, Examination expenses be made in favour of Affiliated Institute and not in favour of other Organization / Unit / Society / Trust / Subsidiary Unit / Holding Company. Proposed Fees structure of the Academic Session 2023-2025 be attached with facilities to the students of Para Medical Courses to be Provided by thelnstitute. All correspondence with the Faculty be made in the exact nomenclature of the Institute and not in the name of any Trust / Society. Name : Joshef Molldh Signature of the Head of Institute Date with stamp1 Availability of Existing Infrastructural Facilities Whether the Institution is in own building or in a rented building (Documentary evidence is required in case of owned bullding and In case of rented building the rent receipt and Agreement with the owner Is required.) The same Is not required for existing Institutions, Accommodation:- ‘The Institution must provide adequate ventilation, lighting and maintain good hygienic condition. The Institute should have adequate number of tollets separately for teaching staff and for male & female students. Administrative area should consist of the following: SI. | Particulars No. Size of the room Remarks of Inspectors Head of Department Room 00am Staff Room: @) Room for Teaching Staff aie Sai ) Room for Technicians 00 Sa ¢) Office Room isos d) Store Room iso san Academic Area should consist of the following: SI. | Particulars Size of the room Remarks of Inspectors 0. | [Class Room 0 Sa Library Saft | Students” Common Room 0 Sat 3. Staff: Non-Teaching staff - ‘a) Regular : SINo. | esignation Name & Qualification Date of Inspectors |] Address & experience Appointment | Remarks | c fie Superintendent foshef Molah ‘Optom = 17 Years 3.112017 2 forte Assistant jonalisa Chakrabory |B Optom = 14 Vears 01.07.2008 3 tore Keeper Tarsan Das 18. Com=T1 Years 15062011 4 ab Technician ita Biswas IB. Se DMLT ~ 18 Years | 18072008 5 Lab Technician outam Bakshi [DMT = 10 Years 09.062012 6 Library Awsitant Subarna Maity plom = 2 Years 01.08.2022 a [Office Peon M.S = 10 Years 2.072012 8 __Ortce Peon [Gopat Kr 01.07.2011 ‘S_— HMouse Keeping FRadha Paswan 07.052015 10 Non-Teaching staff ~ b) Part Time : SI.No. | Designation Name & Qualification —] Date of Inspector's Address &experience_| Appointment _| Remarks T 2 3 4 5 6 7 5Whether potable water is supplied Yes Whether Gas is provided Na Whether electricity is provided : Yes Whether waste disposal management system is followed : Yes Whether the following records are maintained 1. Attendance for staff Yes (Attendance Machine) 2. Acquitence Yes(S/W) 3. Cash Book Yes(S/W) 4, Store material receive and supply (Stock Ledgers) Yes(S/w) 5. Students Attendance Yes(Register) 6. Student Admission Register Yes 7. Dead Stock Register Yes 8. _ Patients’ Attendance Register/Daily Treatment Register in Clinic. Yes(Through EMR) 4. The Training Area should be provided with the following: SI. No. | Particulars Size of the room Remarks of Inspectors 1 Patient Examination [150 Sqft Room 2 Waiting Room for 00 Saft Patient 3 Refraction Room 00 Saft 4 Dark Room [00 Sart 5 ‘Special Examination 200 Sqft Room 6 Museum 7 Tool Room 8 Low Visual Aid Room 5. _ Teaching Staff: (A) Regular Faculty : SI. | Designation Name & [Qualification Pate of Regn | Inspector's No. Address __|& experience Appointment | _No* | Remarks 1 EYESURGEON+ ONS Dr. Arup Kumar Das (MBBS, MS [03.02.2003 e674 2 YESURGEON+ cMO Pr. Rajive Kumar MBBS, MD prezzo pw 3 ge Overt Ut pom Johor WoTaRp Opt Jos.11.2017 ‘Training 7 BLOF SASS jptom Monalisa _[S-Optom 07.2008 amunsuPinson_ Crary 5 forromerrist pfom Ashita. B-Opem (25.07.2017 kherjoe © BR OPTOMETRIST Optom Goutam Bey WrOpIem TOT Z007 a Tale [Gpter Sougata RrOptom prstaoos hakraborty & fpPtomeraist ptom Akramitra B-Optom pt.03.2007 hakraborty 9 10 = = il * In case of Doctor(8) Guest Faculty. : SINo. | Designation) ~~ Name & | Qualification Date of Regn | Inspector's Address. Sexperlence | Appointment | Not | Remarks: + * In case of Doctor 6. List of equipment: SI.No. | Ni ie of Equipment ] No. Required 1 | Sterilisers i 09 2 Formalin Chamber 03 — - 3__ | Chemical Sterilization | cy 4 __ Gama Sterilization wo 5 Slit Lamp 10 6 _| Gonioscopy Lens os 7 |Application Tonometer | 8 | Mon: 02 7 Axtorefractometer 02 10 Keratometer 02 11 | Synaptophore Oy iz 13__ USG 14 = 15 16 31 Set for Refraction 17 | Trial Set For Contact Lens edsWhether the Hospital attached to the Institution Is having the following units: 1) General Out-patients Yes ii) Refractions Yes iii) Contact Lens Yes iv) Squint Yes v) — Ortoptics Yes vi) Glaucoma Yes vii) Retina Yes viii) FFA & Laser Yes ix) Cornea and Eye Bank Yes x) Oculopalasty Yes xi) Neuro-Opthalmology Yes xi) Special Clinics like Uvea, Low Visual alds, etc. Yes xiii) Clinical Pathology Yes xiv) Airconditioned Operation Theatre with Microscope Yes Name Joshe}- Moll wh Signature of the Head of Institute cle Date with stamp acne GRENIER