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1 egkjk"v! vkjksx; fokku fo kihb MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES (An ISO 9001:2008 Certified University) EgljQG] o.kh jksm] ukf'kd & MHASRUL, VANI ROAD, NASHIK website: planning@muhs.ac.in Report of Local Inquiry Committee for Consent of Affiliation (For New Nursing College) (Note : Local Inquiry Committee report should be duly completed in all respect. ) B.Sc. / P.B.B.Sc. Nursing -. Intake :. : Name of Committee Member : Date of Inspection :.. i). ii).. iii).. A) BASIC INFORMATION:- 1) Name and address of the Society / Institution /Charitable Trust:... PIN code : Phone No. (O).. (R). Mobile :. Fax No. Address :. 2) Name and address of the proposed College / Institute :....PIN code :. Phone No. (O).. (R). Mobile :. Fax No. Address :. 1/8

2 3) Registration of Society / Institution / Charitable Trust : Name :... Date of Registration :. i) Public Trust Act, 1950 :. ii) Society s Registration Act, 1860 :... 4) Whether Society / Institution / Charitable Trust is having one of the objectives to impart Nursing Education in the constitution : (Please enclose attested copies of Registration, Constitution and Memorandum of Association) B) Land Details (Details of Land earmarked for the proposed Nursing College) :- 1) A single plot of land measuring not less than 03 acres is available: or 54,000 sq.ft. constructed building as per INC norms 2) If yes, whether the 7/12 extract possesses the name of Society / Institution/Charitable Trust : (Please enclose attested copy of 7/12 extract or lease documents).. C) College Building and Infrastructure Facilities :- (Required for First year as per Council norms) 1) Whether the proposed constructions as per the INC Norms is having minimum sq.ft. area. :- a) Teaching Block : sq. ft. b) Hostel Block : sq. ft. Total : sq. ft. area 2) A Certified copy of architectural plan and layout copy submitted : (Please enclose attested copy of certified architectural plan) 3) Building :- a) Whether separate building is allotted for the proposed Nursing programme. b) Whether the building owned by the society or on rental basis Owned / Rental 2/8

3 c) If the building is rented whether the provisions are made to construct own building within the period of two years. / Not applicable ) Infrastructural facilities : Whether the architectural plan has provision of the following teaching block and Hostel block a) Teaching Block Sr. No. Teaching block Area (in sq. ft.) remarks 1 Lecture Hall (04 numbers) 4@1080=4320 Yes/No I) Fundamental of Nursing 1500 Yes/No 2 II) CHN 900 Yes/No III) Nutrition 900 Yes/No IV) OBG 900 Yes/No 3 Computer Lab 1500 Yes/No 4 Multipurpose Hall / Auditorium 3000 Yes/No 5 Common Room (Male / Female) 2000 Yes/No 6 Staff Room 1000 Yes/No 7 Principal s Room 300 Yes/No 8 Vice Principal s Room 200 Yes/No 9 Library 2400 Yes/No 10 Audio Visual Aids Room 600 Yes/No 11 One room for each HOD 800 Yes/No 12 Faculty Room 2400 Yes/No 13 Provisions for toilets 1000 Yes/No Total b) Hostel Block Sr. No. Hostel Block Area (in sq. ft.) remarks 1 Single Room Yes/No Double Room 2400 Yes/No 2 Sanitary (one Latrine, One Bathroom for 05 students) 500 Yes/No 3 Visitor Room 500 Yes/No 4 Reading Room 250 Yes/No 5 Store Room 500 Yes/No 6 Recreation Room 500 Yes/No 7 Dinning Hall 3000 Yes/No 8 Kitchen & Store 1500 Yes/No Total c) In addition to the above a) & b) whether the provisions for the following are made i) Record Room : ii) Student welfare hall : iii) Indoor games hall : 3/8

4 iv) Play ground : v) Fire extinguisher : vi) Garage : (Please enclose copy of architectural plan ).. D) Hospital & Its Infrastructure : (Necessary infrastructural facilities capable of being developed into a teaching institute in the campus of the proposed Nursing College ) 1) Name of the Own Hospital :. Number of beds:- (a) Registration as per Bombay Nursing Home Act, (b) Registration Under shop Act, (Please attach a copy of Registration certificate) whether it is recognised by MCI : -. Phone No. (O) Fax No.. Address :. Name of Superintendent :. 2) If Attached Hospital(s) :- How many attached hospital(s) :.. Sr. No. Name of Hospital Bed strength Type of Distance No of Patients on Bed registratio Hospital from the day of visit Occupancy n done M F college OPD IPD (Annual) BNH Shop building Act 1 Y/N Y/N Act Y/N Y/N 3 Y/N Y/N 4 Y/N Y/N Note :- 1) As per INC norms the distance between the attached hospital and the proposed college building should be within the radius of 30 k.m. 2) Please attach a copy of Registration for each hospital if affiliated 4/8

5 i) No. of wards :.. (Please enclose list separately with bed strength of each attached hospitals) Sr. Faculty Intake Existing No. Up to 40 Up to 50 1 Medical Surgical Obst. & Gynaecology Paediatric Orthopaedic Psychiatric Total = ii) Well equipped Laboratory : Available / Not Available iii) Para-medical staff appointed : iv) Non-teaching staff appointed : (Please attach separate list of Para-medical & Non-teaching staff) v) Whether adequate Clinical Material is available for fulfilling the requirements of the syllabus and regulations laid down by the Indian Nursing Council E) Teaching Staff : 1) Whether the consent of joining (on Stamp Paper of Rs. 100/-) of Principal is submitted : 2) Whether the undertaking of the Management (on Stamp Paper of Rs. 100/-) regarding appointment of the teachers required for first year at the time of grant of first affiliation is submitted : 3) Whether the Administrative staff is appointed : (All Staff (except Principal / Dean) is not mandatory to be present before the Local Inquiry Committee for Consent of Affiliation. However, the required staff should be appointed at the time of grant of First Affiliation).... F) FINANCIAL POSITION :- 1) Copy of audited statement for last three financial years of the Society/ Trust submitted : 5/8 2) Latest Bank Balance Certificate submitted:

6 3) The financial projection with budgetary provisions for establishment of College for next four years is submitted(cash flow statement) (Please enclose attested copies of Audited Statement, Latest Bank Balance Certificate & Cash Flow Statement). G) Whether proposed college is to be opened in Municipal Corporation Area :- Yes /No If yes, then population of the City :-. H) OVERALL REMARKS BY THE COMMITTEE : Place :. Date :. Name Signature 1) Chairperson. 2) Member.... 3) Member.... 6/8

7 CERTIFICATE OF DEAN / PRINCIPAL This is to certify that the information furnished in above Performa is actually based on facts and as per available record of the College and Hospital is very true. It is further certified that, nothing has been neither hidden nor exaggerated while providing information. Signature Seal Name of Principal/Dean Name of College Place :. Date :. 7/8

8 CERTIFICATE/REMARKS OF THE LOCAL INQUAIRY COMMITTEE We the Local Inquiry Committee members hereby certify that, we have thoroughly inspected the College and Hospital on the date mentioned. We have verified the statements made in the proforma and hereby agree with information supplied by the authorities of the institute. We do not agree with the information supplied by the authorities of the institutes. The statements / data / figures which are not found correct or not based on facts, are encircled by red ink the correct figures are entered near the circle in red ink. (Scratch which ever is not applicable.) Place :-. Date :-. Names Signatures 1) Chairman.. 2) Member... 3) Member... 8/8