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Nursing Home Registration

*Full name of the applicant

 *Full residential address of the applicant

*Technical qualifications, of the applicant

 *Nursing Home contact No

*Name of the nursing home/hospital

 *Place where the nursing home is situated

*Brief description of the construction size and
equipments of the nursing home/hosp. or any
premises used in connection therewith

*Whether the nursing home or any premises used in
connection are used or are to be used for purposes
otherthan that or carrying on a nursing home/hosp
YesNo
*Name age and qualification (s) of the medical
practitioner (s) supervising the nursing home/hosp.

 *Name, age, qualification (s) of the visiting physicians
and surgeons in the nursing home/hosp.

*Total no. of beds


*No. of beds for maternity patients


*No. of beds for other patients: (specialty wise)


*No. of free beds. (if applicable)


*Distance of nursing home/hosp.From nearestblood bank
(in Km)
 *Mention monthly blood Unit’s utilisation.


*Mention annually blood Unit’s utilisation.


*Number of single unit transfusions in a year


*Number of major surgeries done per year.


*Number of minor surgeries done per year.

*Whether operation theatre facility is available at your hospital.
YesNo
*Is your blood bank affiliated to any existing blood bank in the district
YesNo
*From which blood bank you are making blood
available to the patient in present situation?

 *How the cold chain is maintained (while carrying blood
from blood bank to nursing home/hosp.
*Is there any blood storage equipment blood bank refrigerator available with nursing home/hosp
YesNo
*If blood unit is not utilized, (some times) discarded? how it is

 *Whether blood components are utilized at you nursing
home/hosp mention names of blood components.

*Do you regularly send the feed back about successful transfusion or adverse reaction to blood bank.
YesNoSometimes
* Do you wish to create storage facility at your hosp/nursing home,
 if yes how soon
*Do you need any technical support about blood transfusion / component usage/ blood conservation techniques.
YesNo
*Do you practice autologous blood transfusion/ intraoperative salvage techniquesYesNo
*Do you have computer & internet facility.
YesNo
*Name

*Tel. Office/Hospital

*Tel. Residential

Fax

*Mobile

*Email

*Password

 Website

*District:

*Circle:

I solemnly declare that the above statements are true to the best of my knowledge and belief and nothing is concealed.