FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 1

STANDARD ASSESSMENT FORM FOR PG COURSES

SUBJECT – EMERGENCY MEDICINE
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(EMERGENCY MEDICINE)-R-2016 2

STANDARD ASSESSMENT FORM FOR POSTGRADUATE COURSES

(EMERGENCY MEDICINE)

1. Name of Institution:________________________________________________________________
MCI Reference No.: ________________________________________________________________
2. Particulars of the Assessor:- Assessment Date_______________________

Name …………………………………………. Residential Address (with Pin Code)

3.
Designation…………………………………… ……………………………………………...….
Specialty………………………………………. ………………………………………………....
Name & Address of Institute/College Phone .(Off) ……………(Resi.) …………….
……………..………………………………….. (Fax)…………………………………………...
…………………………………………………. Mobile No. ……………………………………
…………………………. E-mail: ………………………………………...
……………………….
(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(EMERGENCY MEDICINE)-R-2016 3

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 seats Recognised Permitted First LOP date

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

(b). Date of last UG PG

inspection for Purpose: Purpose:
Result: Result:
 When was independent department of Emergency Medicine was created :
(Attach copy of orders of competent authority)

 Experience of faculty members only in the department of Emergency Medicine is to be counted

and that also after 2 years special training
(In case of those do not have PG Degree in Emergency Medicine):

4. Total Teachers available in the Department:

Designation Number Name Total Benefit of

Teaching Publications in
Experience Promotion
Professor
Addl./Assoc Professor
Asstt. Professor
Senior Resident
Note: (1) Count only those who are physically present.
(2) Experience of only emergency department is to be counted)

5. Number of beds in the department:

(Count only Beds of Emergency Medicine department. Do not Count casualty or triage beds/trolleys
or other intensive care area beds.)

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 4

6. Clinical workload of the Institution and Department concerned :

Parameter Entire Department of Emergency

Hospital Medicine

On the Day of On the Day of Average of 3 Days

Assessment Assessment Random
OPD attendance upto 2 p.m. N.A.
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 N.A.
Total Number of Deliveries
Total Caesarean Sections
Total Deaths
Emergency department attendance
(in last 24 hours)
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 Emergency

Hospital Medicine

On the Day of On the Day of Average of 3

Assessment Inspection Random Days
Radio-diagnosis MRI N.A.
CT N.A.
USG N.A.
Plain X-rays N.A.
IVP/Barium etc N.A.
Mammography N.A.
DSA N.A.
CT guided FNAC N.A.
USG guided FNAC N.A.
Any other N.A.
Pathology Histopath N.A.
FNAC N.A.
Hematology N.A.
Others N.A.
Bio-Chemistry
Microbiology N.A.
Blood Units Consumed

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 5

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

EmergencyMedicine

S.No. Parameters Year 1 Year 2 Year 3

(Last
Year )
1 Total number of patients attended in
emergency medicine
2 Total number of patients admitted
through Department of Emergency
Medicine
3 Total Number of Major Operations
4 Total Number of Minor Operations
5 Total Number of Normal Deliveries
6 Total Number of Caesarians
Note : Put N.A. for those columns 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)

10 Blood Bank License valid Yes / NO(enclose copy)

Blood component facility available Yes / NO(enclose copy)
Number of blood units stored on the inspection day
Average units consumed daily (entire hospital)
Average number of units issued to Department of
Emergency Medicine per day

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 in Emergency Medicine department
(i) Overall space Adequate / Inadequate
(ii) Space for Skill lab. Adequate/Inadequate
(iii) Space for Disaster area Adequate/Inadequate
(iv) Space for Decontamination Adequate/Inadequate

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 6

15 Library Central Departmental

Number of Books
Number of Journals
Latest journals available upto

16. Department of Emergency Medicine 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 Emergency Medicine
OPD Number of patients
attended to
IPD (Total Number of Number of admissions
Patients admitted) through Department
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 31stDecember )

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

22 Total number of PG Recognized Date of Permitted seats Date of

seats in Emergency seats recognition permission
Department Degree

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FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 7

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 (give names)
2019
2018
2017
2016
2015

24 Other PG courses run by Course Name No. of seats Department

the institution DNB
M.Sc.
Others

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

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

26. Whether other medical super-specialty department exits in the institution …………… Yes/No
(If yes give details)

Name of Beds/Units When LOP for DM seats

department granted & Number of seats

I have physically verified the faculty of Departments of Surgery, Medicine, Anaesthesia, Pulmonary Medicine
(Respiratory Medicine), Orthopedics departments and they have not been counted in Emergency medicine 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

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 8

28. Faculty deficiency, if any

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

Professor
Assoc Professor
Asstt. Professor
Sr. Residents
Jr. Residents
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(EMERGENCY MEDICINE)-R-2016 9

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
Two years Special
Training

Teaching Experience
Designation Institution From To Total
experience
Asstt Professor
Assoc Professor/Reader
Professor
Any Other Grand Total
(Give teaching experience of only department of emergency medicine)
(Not experience of Parent Department)
2. Central Library
 Total number of Books in library: ____________
 Books pertaining to Emergency Medicine: ____________
 Purchase of latest editions of books in last 3 years: Total:___ Emergency Medicine books

 Journals:
Journals Total Emergency Medicine
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. Emergency Department
Number of Beds
Average daily attendance and daily admissions
over past 3 months
Emergency Lab in Emergency Medicine available / not available
department(round the clock):
Emergency OT and Dressing Room available / not available
Staff (Medical/Paramedical) available / not available

Equipment available available / not available

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 10

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 specifications) Yes / No
(v) Number of Blood Units available on inspection day
(vi) Average blood units consumed daily and on inspection day Average daily On Inspection
in the entire Hospital day
( give distribution in various specialties)
Average number of units issued to Department of
Emergency Medicine per 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 case operated Major
daily (Entire hospital) Minor
Day Care
CaesariansDeliveries
Total
Resuscitation arrangements Adequate Equipments
/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(EMERGENCY MEDICINE)-R-2016 11

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 Emergency Medicine

OPD Number of patients
attended to
IPD (Total No. of Number of admissions
Patients admitted) through Department
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 Accommodation UG PG Interns

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(EMERGENCY MEDICINE)-R-2016 12

PART – II (Departmental Information)

1. Department inspected: Emergency Medicine

2. Particulars of HOD
Name: _______________________Age: _________(Date of Birth)__________________

PG Degree Year Institution University

Recognised/ Not
Recognized
Two years Special
Training

Teaching Experience
Designation Institution From To Total
experience
Asstt Professor

Assoc Professor/Reader

Professor

Grand Total
(Count only experience of Emergency Medicine department)

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, year wise 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 (give names)
2019
2018
2017
2016
2015

1. Emergency Departmental facilities:

 When was the independent department of emergency medicine started:………………………
 List the faculty members who has been working in the department since then:………………..…
 Total number of beds in the department:…………………………………………………………..
 Teaching and Resident Staff (Annexed)………………………………………………

I have physically verified that emergency medicine department is separate independent department
Beds/infrastructure of causality and other intensive care areas have not be counted.

Signature of Dean Signature of Assessor

 FORM-MCI-13(EMERGENCY MEDICINE)-R-2016 13

Teaching and Resident Staff:

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 publications
given in promotion
t with n y Mentioning n Period Yes/No, if yes
Year of subject List publications here
passing (no annexures)

Note: 1. Use only the Format provided. DO NOT devise your own format otherwise the information will not be considered. Fill up all columns
2. *Publications: Give only full articles in indexed Journals published during the period of promotion and list them here only. No Annexure will be seen.
3. 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.
4. Experience of Defence services must be supported by certificate from competent authority of the office of DGAFM without which it will not be considered.
5 Count only experience of emergency department
6 Certificate of Two years special training (in case of those not having PG qualification in emergency medicine) must be check & attached.

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 is given the faculty table above.

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FORM-MCI-13(EMERGENCY MEDICINE) 14

6. Has any of these faculty members been considered in PG/UG inspection at any other college or any
other subject in this college during last 2 years. If yes, give details.

Date of Inspection Subject Institution

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 Emergency Medicine)

Parameter On the Day of Average of 3 Days Random

Assessment
Attendance in last 24 hours
New admissions in last 24 hours
Total Beds occupied
Total Required Beds
Average bed Occupancy in last 24
hours (%)
Major Operations
Minor Operations
Normal Deliveries
Caesarean Sections
Note: Put N.A. for those columns not applicable

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

S.No. Parameters Year 1 Year 2 Year 3

(Last
Year )
1 Total number of patients attended
2 Total number of patients admitted
through Department
3 Total Number of Major Operations
4 Total Number of Minor Operations
5 Total Number of Normal Deliveries
6 Total Number of Caesarians

Note : Put N.A. for those columns not applicable

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FORM-MCI-13(EMERGENCY MEDICINE) 15

11. Intensive Care facilities available in the hospital (other than in Emergency Medicine)
I. MICU
 No. of beds: …………………
 Beds occupied on inspection day: …………………
 Average bed occupancy ………………….
 Available equipment ………………….
II. SICU
 No. of beds: …………………
 Beds occupied on inspection day: …………………
 Average bed occupancy ………………….
 Available equipment ………………….
III. NICU
 No. of beds: …………………
 Beds occupied on inspection day: …………………
 Average bed occupancy ………………….
 Available equipment ………………….
IV. PICU
 No. of beds: …………………
 Beds occupied on inspection day: …………………
 Average bed occupancy ………………….
 Available equipment ………………….
V. ICCU
 No. of beds: …………………
 Beds occupied on inspection day: …………………
 Average bed occupancy ………………….
 Available equipment ………………….
VI. Any other intensive care service provided: …………………..

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FORM-MCI-13(EMERGENCY MEDICINE) 16

12. Other emergency services available in department of Emergency Medicine

 Neuro-surgical services
 Emergency Operation theatre (Major & Minor)
 Emergency services for Radiological procedure like –
 Dialysis service

Emergency lab. Available/Not available

ABG Available/Not available
ECG Available/Not available
Portable x-ray Available/Not available
USG Available/Not available
CT/MRI Available/Not available
Echo-Cardiography Available/Not available
Endoscopy Available/Not available
Dialysis Available/Not available
Rigid & Flexible Bronchoscopy Available/Not available
PAC Available/Not available
Pre-Operative beds Available/Not available
Post operative beds Available/Not available
Emergency services for Gynecological and Available/Not available
Obstetrical patients
Triage Available/Not available
Emergency Registration Available/Not available
Medico-legal services Available/Not available
Police outpost near ED Available/Not available
Others

(These facilities are integral part of Emergency Medicine Department and should be available in the
department even if super specialty departments exist in the institution)

13. Departmental Library:

 Total No. of Books.
 Purchase of latest editions in last 3 years.
 No. of Journals

14. Departmental Research Lab.

 Space
 Equipment
 Research projects utilizing Deptt research lab.

15. Departmental Museum (Wherever applicable).

 Space:
 No. of specimens
 Charts/ Diagrams.

16. Departmental Space:

 No. of rooms
 Patient Exam. arrangement:
 Equipments
 Teaching Space
 Waiting area for patients.
 Skill Laboratory

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE) 17

17. Office space:

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

18. Clinico- Pathological conference Held/not held Frequency

19. Death Review Meetings Held/not held Frequency

20. Submission of data to national authorities if any -

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

(List here only – No annexure to be attached, provide number of equipments)

22. 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

23. Any other information.

Signature of Dean Signature of Assessor

FORM-MCI-13(EMERGENCY MEDICINE) 18

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 be

attached).

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