Faculty/ SR/ Tutor/ Demonstrator Declaration Form
Name of the College: MAMATA ACADEMY OF MEDICAL SCIENCES
Submission date _ _ /_ _ /_ _ _ _
Note: It is the responsibility of the Dean to ensure that the submitted Declaration form is ONLY of a Faculty member who is working as a full-
time employee of the college
1. Name of Faculty: Dr K PRAVEEN KUMAR
2. Age & Date of birth: 36(Years), 24/ 06_ / 1987
3. Present Designation: ASSISTANT PROFESSOR
Attach a recent
a. Appointment order: Certified copy of order at this institute attached: Yes / No
b. Department: PSYCHIATRY
c. College/Institute: MAMATA ACADEMY OF MEDICAL SCIENCES
d. City / District: BACHUPALLY
e. Appointment: (i) Regular / Contractual /Ad-hoc basis
(ii) Full time / Part time
(iii) With Private practice / Without Private practice
f. Date of appearance in last MCI/NMC assessment:
i. UG / PG / Any other: U.G
ii. Name of College: MAMATA ACADEMY OF MEDICAL SCIENCES,
BACHUPALLY
iii. Whether appeared and accepted at the same College: Yes / No
iv. Whether appeared and accepted for the same designation: Yes / No
v. Whether retired from Government Medical College: Yes /No
vi. If yes, designation at the time of retirement:
Signature of the Faculty Signature & Seal of Dean
4. Complete Residential Address of the employee:
a. Present: Staff quarters 407, Mams Hospital, Bachupally, Hyderabad, Telangana - 500090
b. Permanent: H.No. 1/48 A, Nadi street, Mittameedapalle village and post, Rajampet,
Annamayya district, Andhrapradesh, 516125
5. Copy of Proof of Residence submitted and original verified: Yes / No
(Only copies of Passport/Aadhar card/Voter ID/Passport/Electricity bill/Landline Phone bill will be considered)
6. Contact details:
a. Office telephone with STD code:
b. Residence telephone with STD code:
c. Mobile Phone Number: 7032211964
d. Email address:
[email protected]7. Date of joining the present institution: 18/01/ 2021
8. Joining report verified / attached Yes / No
9. Have you attended the Basic Course Workshop (BCME), Curriculum Implementation Support
Programme (CISP-i/ii/iii), Advanced Course in Medical Education (ACME) for training in
MET: No.
(If Yes, provide certificate/s )
a. at MCI/NMC Regional MET Centre: Yes /No.
b. at your college under Regional / Nodal Centre observership: Yes / No
c. Any other MET certificates may be attached
10. Educational Qualifications:
Name of College & Registration number Name of State
Degree Year
University with date of Medical council
registration
2012 Sri Venkateshwara Medical No:80064 Telangana State Medical
MBBS College, Tirupati. Dt: 05.12.2023 (TSMC) Council
Dr. NTR University of Health Dt: 29.05.2013 (APMC)
Sciences, Vijayawada.
2020 Sri Venkateshwara Medical No: 80064 Telangana State Medical
MDPSYC College, Tirupati. Dt:29.12.2023 (TSMC) Council
HIATRY Dr. NTR University of Health Dt:14.10.2020 (APMC)
Sciences, Vijayawada.
PhD
a. MD/MS subject:
b. DM/MCh subject:
c. PhD subject:
Note: For PG & Post PG qualifications, particulars of Registration of Additional Qualification certificates
are to be furnished for them to be accepted. Strike out whichever section is not applicable.
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11. Copies of educational qualifications:
a. Copies of MBBS & PG Degree certificates verified and attached: Yes / No
b. Copies of MBBS & PG Degree Registration verified and attached: Yes / No
12. Details of Teaching experience till date:
Designation* Department Institution From To Total
Junior Resident _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Junior Resident Psychiatry Sri Venkateshwara 05/06/2017 04/06/2020 3 Years
Medical College,
Tirupati.
Senior Resident Psychiatry Mamata Academy of 18.01.2021 30.09.2022 1Year&8
Medical Sciences, Months
Hyderabad.
Assistant Professor Psychiatry Mamata Academy of 01.10.2022 Till to Date
Medical Sciences,
Hyderabad.
Professor _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
* Write NA (Not Applicable) for the designations not held
To be filled in by personnel from Indian Defense Services ONLY:
Designation Institution* From To Total
_ _/_ _/_ _ _/_ _/_
Graded Specialist _ _
(y) (m)
_ _/_ _/_ _ _/_ _/_
Classified Specialist _ _
(y) (m)
_ _/_ _/_ _ _/_ _/_
Advisor _ _
(y) (m)
* Note: Documents in support of each posting to be furnished for verification
13. Have you been considered in UG/PG, MCI/NMC inspection at any other medical
college in a teaching or administrative capacity during last 3 years. If yes, please
give details:
Designation Subject College Dates
14. Number of lectures / small group teachings/ self-directed learning sessions/ clinics/ etc
taken and topics covered in last academic year (attach additional sheet, if required)
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S.No. Date Lecture/ SGT/SDL/ Clinic/ others Topic
01/06/2023 Lecture PS 1.1
SGT PS 1.2
SGT PS 1.3
Lecture PS 1.4
15/06/2023 Lecture PS 2.1
Lecture PS 2.2
SGT PS 2.3
SGT PS 2.4
Lecture PS 2.5
29/06/2023 Lecture PS 3.1
SGT PS 3.2
SGT PS 3.6
Lecture PS 3.8
SGT PS3.10
Lecture PS 3.11
Lecture PS 3.12
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15. Details of employment before joining the present institution:
a. Name of College/Institution:
b. Designation: Date on which relieved: _ _ / _ _ / _ _ _ _
c. Reason for being relieved: Tendered resignation / Retired / Transferred / Terminated
d. Relieving order issued by previous institution verified and attached: Yes / No
16. PAN Card Number: CSEPK 5156R
17. Aadhar card Number:614574176448
18. I have drawn total emoluments from this college in the current financial year as under:
Month Amount Received TDS
/ Year
Jan/
Feb/
March/
April/
May/
June/
July /
August/
September/
October/
November/
December/
19. Number of Research articles in Indexed Journals:
a. International Journals: ____
b. National Journals: ____
c. State / Institutional Journals: _ _ _ _
20. Details of other publications:
a. Number of Books published:
b. Number of Chapters in books:
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21. Any other information/ achievements/ patents:
22. Oral presentations: in zonal
conference:
State conference:
National conference:
International conference:
23. Poster presentations: in zonal/ State/ National/ International Conference.
24. Awards/ prizes:
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DECLARATION
1. I, Dr. K. PRAVEEN KUMAR am working in the capacity of Assistant Professor in
the Department of PSYCHIATRY at MAMATA ACADEMY OF MEDICAL SCIENCES
Medical College and do hereby give an undertaking that I am employed as a full time teaching
faculty, working from 9:00 A.M. to 4:30 PM daily at this Institute. If required I attend emergency
duties.
2. I have not made myself available to any other Medical College/Institution in any discipline,
in the capacity of a teaching faculty, administrator or advisor in the current academic year
for the purpose of NMC/MCI assessments.
3. I do hereby solemnly declare that (tick the applicable clause):
a. I state that I am not doing any Private Practice or working in any other hospital
during college hours.
b. I practice at Nursing Home / Clinic / Hospital
in the city of in State and my hours of private
practice are from _ _:_ _ AM/PM to AM/PM.
4. I am not working in any other medical/dental college in or outside the State in any
capacity: Regular/Contractual/Ad-hoc or Full time/Part time/Honorary.
5. I declare that I have provided all details with regard to my work and teaching experience
and no information has been concealed by me.
6. I do solemnly declare that all the details/information furnished by me in this declaration
form is absolutely true and correct, and all the documents/certificates that were made
available by me for verification or have been submitted by me along with this declaration
form are authentic. In the event of any information furnished or statement made in this
declaration subsequently turning out to be false/incorrect or any document/s or
certificate/sis/are found to be out of order, or it comes to light that there has been
suppression of any material information, I understand and accept that it shall be considered
as gross misconduct thereby rendering me liable to disciplinary and/or legal proceedings. It
might also lead to suspension/cancellation of my Registration with the State Medical
Council and/or removal of my name from the Indian Medical Register.
Date:
Place:
(Signature of the Faculty)
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ENDORSEMENT
1. This endorsement is the certification that the undersigned has satisfied herself/himself
about the correctness, authenticity and veracity of the content of this declaration form in its
entirety and endorsed the above declaration as true and correct. I have personally verified
all the certificates/documents submitted by the teaching faculty with the original
certificates and documents that were submitted by her/him to the Institute and
confirmed the same with the concerned Institute and have found them to be correct
and authentic.
2. I also confirm that Dr. K PRAVEEN KUMAR is not indulging in private practice of any
kind or carrying out any other professional or other commercial activity during college
working hours, from 9:00AM to 4:30PM, since she/he has joined the Institute.
3. In the event of this declaration turning out to be false or incorrect or any part of this
declaration subsequently turning out to be false or incorrect or it comes to light that there
has been suppression of any material information, it is understood and accepted that the
undersigned shall also be equally responsible besides the declarant herself/himself, for the
mis-declaration or mis-statement.
Date:
Place:
Signature (Head of Signature (Head of Institute)
Dept.) with official seal with official seal
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CHECKLIST
Sl Documents Submitted
1. Recent Passport size photo of Employee, Signed by Dean/Principal of college Yes / No
2. Photo ID proof (Govt. Authority issued): Passport/PAN Card/Voter ID/Aadhar Card Yes / No
3. Certified copy of Appointment order of the present Institute. Yes / No
4. Proof of Residence: Passport/Voter Card/Electricity/Landline phone bill/ Aadhar Card Yes / No
5. Joining report at the present institute. Yes / No
6. Copies of MBBS, PG, PhD degrees (as applicable). Yes / No
7. Copies of MBBS, PG, PhD degree Registration Certificates (as applicable). Yes / No
8. Copy of experience certificates of all teaching appointments before joining present post. Yes / No
9. Relieving order from the previous institution/posting. Yes / No
10. Copy of PAN Card, AADHAR card Yes / No
11. Letter head (in case of teachers who are practicing) Yes / No
12. Copy of letter from affiliating University recognizing as UG teacher Yes / No
13 Copy of letter from affiliating University recognizing as PG teacher (for PG assessment) Yes / No
14 Copy of MET certificates: rBCW/ BCME/ CISP/ ACME/ Others Yes / No
Signature of Faculty Signature of the HoD.
Date: Date:
Signature of Head of Institute
Date:
NOTE
I) This Declaration Form will not be accepted and the Faculty member will not be considered as a
Teaching Faculty in case any of the documents listed above are not enclosed/attached with the
Declaration Form.
II) The Faculty member will not be considered as a Teaching Faculty if the original Appointment letter,
Relieving order, Experience certificates, Government Photo ID, Degrees, Registration Certificates,
PAN Card, Aadhar Card, State Medical Council ID (if issued) are not produced for verification at the
time of assessment.
III) Faculty members must submit the revised Declaration form in this format only, Submissions in the
old format will be rejected and Faculty members will not be considered as Teaching Faculty.
