FORM-MCI-13(ORTH)-R-2016 1

STANDARD ASSESSMENT FORM FOR PG COURSES

SUBJECT – ORTHOPAEDICS
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.

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 2

STANDARD ASSESSMENT FORM FOR POSTGRADUATE COURSES

(ORTHOPAEDICS)

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:

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 3

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 4

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 Recognised Permitted First LOP

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

(b). Date of last UG PG

inspection for Purpose: Purpose:
Result: Result:

4. Total Teachers available in the Department:

Designation Numbe Name Total Benefit of

r Teaching Publications in
Experience Promotion
Professor
Addl./Assoc
Professor
Asstt.
Professor
Senior
Resident
Note: Count only those who are physically present.

5. Number of Units with beds in each unit:

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 5

6. Clinical workload of the Institution and Department concerned :

Parameter Entire Hospital Department of Orthopaedics

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 Orthopaedics

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

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 6

8. Year-wise available clinical materials (during previous 3 years) for department of

Orthopedics

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)

1 Blood License valid Yes / NO(enclose

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

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 7

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 Librar Central Departmental

y
Number of Books pertaining to
orthopedics
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

18. 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 Orthopedics

OPD OPD
IPD (Total Number IPD (Total Number
of Patients admitted) of 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 31st December )

20. Accommodation for staff Available / Not available

21 Hostel Accommodation UG PG Interns

No. Boys Girls Boys Girls Boys Girls

No. of Students
No. of Rooms
Status of Cleanliness
Signature of Dean Signature of Assessor
FORM-MCI-13(ORTH)-R-2016 8

2 Total number of PG Recognize Date of Permitted Date of

2 seats in the d seats recognitio Seats permission
concerned subject n
Degree
Diplom
a

23. 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

2 Other PG courses run Course Name No. of Department

4 by the institution seats
DNB
M.Sc.
Others

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

Year Stipend paid in Govt. colleges by Stipend paid by the Institution*
State Govt.
Ist Year
IInd Year
IIIrd Year
* Stipend shall be paid by the institution as per Govt. rate shown above.

26. Whether other medical superspecialty 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 departments and they
have not been counted in orthopedics department inspection.

27. 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

28. Faculty deficiency, if any

Designation Faculty available Faculty required Deficiency, if any
(number only)

Professor
Assoc Professor
Asstt. Professor
Signature of Dean Signature of Assessor
FORM-MCI-13(ORTH)-R-2016 9

Sr. Residents
Jr. Residents
Tutor/ Demonstrator
Any Other
* Faculty Attendance Sheet duly signed by concerned faculty must be enclosed.

29. 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)

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 10

PART – I
(INSTITUTIONAL INFORMATION)

1 Particulars of Director / Dean / Principal:

(Who so ever is Head of Institution)

Name: _______________________Age: _________(Date of Birth)__________________

PG Degree Subject Year Institution University

Recognised /
Not Recognized

Teaching Experience
Designation Institution From To Total
experience
Asstt Professor
Assoc Professor/Reader
Professor
Any Other Grand Total

2. Central Library
 Total number of Books in library: ____________
 Books pertaining to Orthopaedics: ____________
 Purchase of latest editions of books in last 3 years: Total:_____ Orthopaedics books

 Journals:
Journals Total Orthopaedics
Indian
Foreign

 Year / Month up to which latest Indian Journals available: _________________

 Year / Month up to which latest Foreign Journals available: _________________
 Internet / Med pub / Photocopy facility: available / not available
 Library opening times: _________________
 Reading facility out of routine library hours: available / not available
(obtain list of books & journals duly signed by Dean)

3. Casualty:/ Emergency Department

Space
Number of Beds
No. of cases (Average daily OPD and
Admissions):
Emergency Lab in Casualty (round the available / not available
clock):
Emergency OT and Dressing Room
Staff (Medical/Paramedical)

Equipment available

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 11

4 Blood Bank

(i) Valid License(copy of certificate be annexed) Yes / No

(ii) Blood component facility available Yes / No
(iii All Blood Units tested for Hepatitis C,B, HIV Yes / No
)
(iv Nature of Blood Storage facilities (as per Yes / No
) specifications)
(v) Number of Blood Units available on inspection day
(vi Average blood units consumed daily and on Average On
) inspection day in the entire Hospital daily Inspection
( give distribution in various specialties) day

5. Central Research Lab:

 Whether it exists? Yes No
 Administrative control:
 Staff:
 Equipment:
 Workload:
6. Central Laboratory:
 Controlling Department:
 Working Hours:

Radiotherapy (Optional)
Radiotherapy
Teletherapy
Brachy therapy

7. Operation Theatres:

AC / Non AC Number of OTs functional

per day
Numbers Number of days operations
carried out
Pre-Anaesthetic clinic Average No. of cases Major
operated daily (Entire Minor
hospital) Day Care
Caesarian
Delivery
Total
Resuscitation Adequate Equipments
arrangements /Inadequate
8. Central supply of Oxygen / Suction: Available / Not available
9. Central Sterilization Department Adequate / Not adequate
10. Laundry: Manual/Mechanical/Outsourced:
11. Kitchen Gas / Fire
12. Incinerator: Functional / Non functional Capacity: Outsourced
13. Bio-waste disposal Outsources / any other method
14. Generator facility Available / Not available
15. Medical Record Section: Computerized / Non computerized
 ICD10 classification Used / Not used

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 12

16. Total number of OPD, IPD and Deaths in the Institution and concerned department
during the last one year:

In the entire hospital In the department of Orthopedics

OPD OPD
IPD (Total No. of IPD (Total No. of
Patients admitted) Patients admitted)
Deaths Deaths

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

Note: 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.)

18. Recreational facilities: Available / Not available

Play grounds Gymnasium

19 Hostel UG PG Interns
Accommodation Boys Girls Boys Girls Boys Girls
No. of Rooms
No. of Students
Status of cleanliness

20. Residential accommodation for Staff / Paramedical staff Adequate / Inadequate

21. Ethical Committee (Constitution):

22. Medical Education Unit (Constitution)

(Specify number of meetings held annually & minutes thereof)

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 13

PART – II (Departmental Information)

1 Department inspected: ORTHOPAEDICS

2 Particulars of HOD

Name: _______________________Age: _________(Date of Birth)__________________

PG Degree Year Institution University

Recognised/ Not
Recognized

Teaching Experience
Designation Institution From TO Total
experience
Asstt Professor

Assoc Professor/Reader

Professor

Grand Total

a) Purpose of Present inspection:

Grant of Permission/ Recognition/ Increase of seats /
Renewal of recognition/Compliance Verification

b) Date of last MCI inspection of the department: __________________________

(Write Not Applicable for first MCI inspection)
c) Purpose of Last Inspection: ___________________________________________
d) Result of last Inspection: _________________________________________
(Copy of MCI letter be attached)

3 Mode of selection (actual/proposed) of PG students.

4 If course already started, yearwise number of PG students admitted and available

PG teachers during the last 5 years:
Year No. of PG students admitted No. of PG Teachers available in the dept.
Degree Diploma (give names)
2016
2015
2014
2013
2012

Signature of Dean Signature of Assessor

 FORM-MCI-13(ORTH)-R-2016 14

Unit wise Teaching and Resident Staff:

Unit _________ Bed Strength _________________ :
S. Designatio Name with Date of Birth Nature of PAN PG QUALIFICATION Experience Signature of
No n employment Number Date wise teaching experience with designation & Institution Faculty
. Full time/part TDS Member
time/Hon. deducte
d
Subjec Institutio Universit Designation Institutio From To Total * Benefit of
t with n y Mentioning n Period publications given
Year of subject in promotion
passing Yes/No, if yes
List publications
here
(no annexures)

Note: 1. Unit wise teaching / Resident staff should be shown separately for each Unit in the Proforma.
2. Use only the Format provided. DO NOT devise your own format otherwise the information will not be considered. Fill up all columns
3. *Publications: Give only full articles in indexed Journals published during the period of promotion and list them here only. No Annexure will be seen.
4. Incase of DNB qualification name of the institution/hospital from where DNB training was done and year of passing must be provided. Simply saying National Board of
Examinations, New Delhi is not enough. Without these details DNB qualification holder will be summarily rejected.
5. Experience of Defence services must be supported by certificate from competent authority of the office of DGAFM without which it will not be considered.

I have verified the eligibility of all faculty members for the post they are holding (based on experience certificates issued by competent authority of the place of
working). Their experience details in different Designations and unitwise distribution is given the faculty table above.

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 15

6. Has any of these faculties member considered in PG/UG inspection at any other college
after 01.03.2015. If yes, give details.

Date of Subject Institution

Inspection

7 List of Faculty joining and leaving after last inspection:

DESIGNATIONS NUMBER NAMES

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

8 List of Non-teaching Staff in the department: -

S.No. Name Designation

9 Available Clinical Material: (Give the data only for the department of Orthopaedics)

Parameter On the Day of Average of 3 Days

Assessment 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
Normal Deliveries
Caesarean Sections
Deaths
Note : Put N.A. for those columns not applicable

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 16

10 Year-wise available clinical materials (during previous 3 years) for department of Orthopaedics
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 columns not applicable

11 Intensive Care facilities

I. ICU
 No. of beds: …………………
 Beds occupied on inspection day: …………………
 Average bed occupancy ………………….
 Available equipment ………………….
II. Any other intensive care service provided: …………………..

12 Specialty clinics being run by the department and number of patients in each

S.No. Name of the Days on which Timings Average No. of Name of

Clinic held cases attended Clinic In-
charge
1 Fracture clinic
2 CTEV clinic
3 Spine Clinic
4 Arthoplasty Clinic
5 Hand Clinic
6 Arthroscopy
Clinic
7 Any other

13 Services provided by the Department.

(a) Joint replacement (Hip, Knee)

(b) Trauma services
(c) Arthoplasty
(d) Arthroscopy
(e) Spine surgery
(f) Physiotherapy Section.
(f) Investigative facilities like Nerve conduction, EMG etc.
(g) Plaster room/Plaster cutting room
(h) Other special diagnostic facilities being provided by the department.

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 17

14. Operation Theatres

(a) Number of theatres
(b) Number of OT Tables

15. Recovery Room (enclose in detail in separate sheet, if required)

(a) Space
(b) No. of beds

16 Departmental Library:
 Total No. of Books.
 Purchase of latest editions in last 3 years.
 No. of Journals
17 Departmental Research Lab.
 Space
 Equipment
 Research projects utilizing Deptt research lab.
18 Departmental Museum (Wherever applicable).
 Space:
 No. of specimens
 Charts/ Diagrams.

19 Space: OPD IPD

No. of rooms
Patient Exam. arrangement:
Equipments
Equipments
Waiting area for patients.

20 Office space:

Department Office office Space for Teaching Faculty

Space for Clear Yes/No HOD
Staff (Steno/Clerk) Yes/No Professors
Computer/Typewriter: Yes/No Assoc. Prof.
Storage space for files Yes/No Asstt. Prof.
Residents

21. Clinico- Pathological conference

22. Death Review Meetings

23. Submission of data to national authorities if any -

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 18

24 Equipments: List of important equipments available and their functional status

(List here only – NO annexure to be attached)

Arthroscope

Image Intensifier

Hip Arthoplasty set

Knee Arthoplasty set

Fracture Fixation set

Spine surgery set

DHS set

Inter locking nail set

Any other

25. Academic outcome based parameters

(a) Theory classes taken in the last 12 months – Number ________

(Dates, Subjects, Name & Designation Available & Verified/
of teachers, Attendance sheet) Not available

(b) Clinical Seminars in last 12 months Number ________

(Dates, Subjects, Name & Designation Available & Verified/
of teachers, Attendance sheet) Not available

(c) Journal Clubs held in last 12 months Number ________

(Dates, Subjects, Name & Designation Available & Verified/
of teachers, Attendance sheet) Not available

(d) Case presentations held in last 12 months Number ________

(Dates, Subjects, Name & Designation Available & Verified/
of teachers, Attendance sheet) Not available

(e) Group discussions held in last 12 months Number ________

(Dates, Subjects, Name & Designation Available & Verified/
of teachers, Attendance sheet) Not available

(f) Guest lectures held in last 12 months Number ________

(Dates, Subjects, Name & Designation Available & Verified/
of teachers, Attendance sheet) Not available

26. Any other information.

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 19

PART III

POSTGRADUATE EXAMINATION
(Only At the Time of Recognition Inspection)

1. Minimum prescribed period of training.

(Date of admission of the Regular Batch appearing in examination)

2. Minimum prescribed essential attendance.

3. Periodic performance appraisal done or not?

4. Whether the candidates appearing in the examination have submitted their thesis six
months before appearing in examination as per PG Regulations.2000?

5. Whether the thesis submitted by the candidates appearing in the examination been
accepted or not?

6. Whether the candidates appearing in the examination have (i) presented one poster (ii)
read one paper at National/State conference and presented one research paper which has
been published/accepted for publication/sent for publication during period of their
postgraduate study period.

7. Details of examiners appointed by Examining University.(Give Details here. No

Annexures)

8. Whether appointment of examiners, their eligibility & conduct of examination is as per

prescribed MCI norms or not ?

9. Standard of Theory papers and that of Clinical / Practical Examination:

10. Year of 1st batch pass out (mention name of previous/existing University)

Degree Course ________________

Note: (i) Please do not appoint retired faculty as External Examiner

(ii) There should be two internal and two external examiners. If there are no two
internal examiners available in the department then only appoint three external
examiners.

Signature of Dean Signature of Assessor

FORM-MCI-13(ORTH)-R-2016 20

Signature of Dean Signature of Assessor