Mohan Foundation(Multi Organ Harvesting Aid Network)-THO Form

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