FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 1

STANDARD ASSESSMENT FORM FOR PG COURSES

SUBJECT - DERMATOLOGY, VENEREOLOGY & LEPROSY

INSTRUCTIONS FOR DEANS/PRINCIPALS AND ASSESSORS

1. Please read the Standard Assessment Form (SAF) carefully before filling. You will NOT be allowed
to make any changes in the Data after it has been submitted.

2. Do NOT leave any section of the SAF or part thereof unanswered. Incompletely filled up forms shall
be summarily rejected without any intimation to the college/institution.

3. Do NOT edit or modify any part of the SAF. Tampering with the format of these forms will render
your submission invalid.

4. Do NOT attach Annexures or enclosures. All the information furnished should be in the appropriate
sections of the SAF. Annexures and Enclosures will NOT be considered.

5. Do NOT attach experience certificates with SAF. It is mandatory to submit Experience certificate/s
issued by the competent authority from place/s of work (from the office of the DGAFMS in case of
personnel of the Indian armed forces) along with the Faculty declaration forms, failing which
information about work experience will not be considered.

6. In case of faculty/residents with DNB qualification, full Name of the hospital/institution where DNB
training was obtained and year of passing should clearly be mentioned failing which they shall NOT
be considered. Merely mentioning National Board of Examinations, New Delhi, shall not suffice.

7. The Dean/Principal is responsible for filling up the entire form and signing at appropriate places.

8. If promotions are after the cut-off dates (21/07/2013 for Professors; 21/07/2014 for Associate
Professors) and benefit of publications has been given in promotion before the cut-off dates, list the
publications immediately below the name of faculty in the format: Title of Paper, Authors, Citation of
Journal, details of Indexing in the faculty table. Photocopies of published articles should be attached
with the Faculty declaration forms failing which they will not be considered. Please provide details of
full/original articles ONLY. Case reports, review articles and abstracts shall NOT be considered.

9. Do NOT use abbreviations for names of Medical Colleges in the SAF and Declaration Forms.

INSTRUCTIONS FOR ASSESSORS:

10. Please follow all instructions carefully. Instructions marked NOTE: are repeated in various sections
of the SAF to ensure compliance for the sake of consistency and uniformity.

11. Only Faculty members and Resident doctors who sign the attendance sheet by 11:00 A.M., present
themselves for subsequent verification and are found eligible must be considered. In addition, all those
who are on NMC permitted leave, or on NMC/Court duties are to be considered. Please ensure that
signatures of faculty members and resident doctors are obtained in the Faculty table.

12. OPD attendance up to 2:00 P.M. and Bed occupancy till 10:00 A.M. must be considered, without
any exceptions. Please adhere to instructions regarding time very strictly.

13. Data for Radiodiagnosis investigations, Central Clinical Laboratories, Blood Bank etc., entered in
the SAF must be verified with physical records/registers.

14. Information regarding Births and Deaths to be verified from Birth/Death registration forms sent by
hospital to the Registrar of Births/Deaths.

15. Assessors may write confidential remarks not shown in the assessment report on the page marked
“Remarks of Assessor”. Do NOT send/attach separate confidential letter/s.

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 2

STANDARD ASSESSMENT FORM FOR POSTGRADUATE COURSES

(DERMATOLOGY, VENEREOLOGY & LEPROSY)
1. Name of Institution: ______________________________________________________________
NMC Reference No.: _____________________________________________________________
2. Particulars of the Assessor: Date of Assessment _ _/_ _/_ _ _ _.

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

Designation…………………………………… ……………………………………………...….
Specialty………………………………………. ………………………………………………....
Name & Address of Institute/College Phone No. (Off) …………(Res) …………….
……………..………………………………….. (Fax)…………………………………………...
…………………………………………………. Mobile No. ……………………………………
………………………….………………………. E-mail: ………………………………………...

3. Institutional Information:
A. Particulars of the Institution/College

Chairman/ Director/ Medical

Institution/College
Health Secretary Dean/ Principal Superintendent

Name

Address

State

Pin Code
Phone Nos.
Office
Residence
Fax
Mobile No.
E-mail

B. Particulars of Affiliating University

University Vice Chancellor Registrar

Name

Address

State

Pin Code
Phone Nos.
Office
Residence
Fax
Mobile No.
E-mail:

(Note: Dermatology, Venereology & Leprosy may be referred to as DVL for convenience)

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 3

SUMMARY
Date of Assessment: _ _ /_ _ /_ _ _ _. Name of Assessor: _______________________

Name of Institution Director / Dean / Principal

(Govt./Pvt.) (Whosoever is Head of the Institution)
Name
Age & Date of Birth
Teaching experience
PG Degree (Recognized/Non-R)
Discipline/Subject

Department Head of Department

inspected
Name
Age & Date of Birth
Teaching experience
PG Degree (Recognized/Non-R)

3 (a) Recognized Permitted First LOP date when

Number of UG seats (Year: ) (Year: ) MBBS course was first
permitted

3 (b) UG PG
Date of last assessment Purpose: Purpose:
for
Result: Result:
4. Total Teachers available in the Department:

Designation Number Name Total teaching Benefit of publications

experience in promotion
Professor

Addl/Assoc Professor

Asst Professor

Senior Resident

Note: Only those who are physically present to be considered.

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 4

5. Number of Units with beds in each unit:

Number of Units
Number of beds in each Unit

6. Clinical workload of the Institution and Department of DVL:

Entire Hospital Department of DVL

Particulars On Day of On Day of Avg of 3 Days
Assessment Assessment Random
OPD attendance up to 2:00 P.M.
Total number of new admissions
Total Beds occupied at 10:00 A.M.
Total no. of Required Beds
Bed Occupancy at 10:00 A.M. (%)
No. of Major Operations
No. of Minor Operations
No. of Day Care Operations
Total no. of Deliveries
Total no. of Caesarean Sections
Total no. of Deaths
Casualty attendance
Note:
i. OPD attendance to be considered only up to 2:00 P.M. and Bed occupancy till 10:00 A.M.
ii. Verify data from Birth/Death registration forms sent by hospital to the Registrar of Births/Deaths.

7. Investigative Workload of entire hospital and Department of DVL.

Entire Hospital Department of DVL

Particulars On day of On day of Avg of 3
assessment assessment random days
Radio-diagnosis MRI
CT
USG
Plain X-rays
IVP/Barium etc.
Mammography
DSA
CT guided FNAC
USG guided FNAC
Any other
Pathology Histopathology
Cytopathology
Hematology
Others
Biochemistry
Microbiology
Units of blood consumed

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 5

8. Year-wise available clinical material of the department of DVL (past 3 calendar years).

Average daily workload Year 1 Year 2 Year 3

1. Number of patients in OPD
2. Number of patients admitted (IPD)
3. Number of Routine Procedures
4. Number of Special Procedures
5. Any other special service
Note: (Past year)
i. Calendar year: 1st January to 31st December of the year considered.
ii. IPD means total number of patients admitted (Not total occupancy of the year)

9. Publications from the department during the past 3 years:

(Only original articles published in indexed journals are to be accepted. Case reports, abstracts and
review articles are not to be included).

10. Blood bank

License valid Yes / No

Blood component facility available Yes / No
Number of units stored on the day of Assessment
Average number of units consumed daily (entire hospital)

11. Specialized services provided by the department: Adequate / not adequate

12. Specialized Intensive Care services provided by the department: Adequate / not adequate

13. Specialized equipment available in the department: Adequate / Inadequate

14. Space (Offices, Teaching areas) Adequate / Inadequate

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 6

15. Library:

Particulars Central Departmental

Number of Books pertaining to DVL
Number of Journals
Latest journals available up to

16. Emergency/Casualty: Number of Beds: _ _ _Available equipment: _ _ _ Adequate / Inadequate

17. Common facilities:
1. Central supply of Oxygen / Suction: Available / Not available
2. Central Sterile Supply Department Adequate / Not adequate
3. Laundry services: Available/Not available
4. Dietary services Available/Not available
5. Bio-Medical Waste disposal Outsourced / any other method
6. Generator facility Available / Not available
7. Medical Record Section: Computerized / Non computerized
8. ICDX classification Used / Not used

18. Number of OPD, IPD cases & Deaths in the Institution and department of DVL (past year).

In the entire hospital In the department of DVL

OPD OPD
IPD (Admissions) IPD (Admissions)
Deaths Deaths

19. Accommodation for staff: Available / Not available

20. Hostel accommodation:

UG PG Interns
Detail
Boys Girls Boys Girls Boys Girls
Number of Students
Number of Rooms
Status of Hygiene/Cleanliness

21. Total number of PG seats

Recognized Date of
Permitted seats Date of permission
seats recognition

Degree

22. Year wise PG students admitted (in the department inspected) during the preceding 5 years
and available number of PG teachers

Year Number of PGs admitted Number and Names of PG Teachers available

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 7

23. Other PG courses run by the Institution

Course Name No. of seats Department/s

DNB
M.Sc.
Others

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

Year Stipend in Govt. Colleges paid by State Govt. Stipend paid by the Institution*
1st Year
2nd Year
3rd Year
* Stipend shall be paid by the institution as per Government rates shown above.

25. List of Departmental Faculty appointed / relieved after the last Assessment:

Names of faculty members

Designation Number
Appointed Relieved
Professor

Associate Prof.

Assistant Prof.

SR/Tutor/Demons.

Others

26. Faculty deficiency, if any

Designation Numbers available Numbers required Deficiency, if any

Professors
Associate Professors
Assistant Professors
Senior Residents
Junior Residents
Tutors/Demonstrators
Any Others
* Faculty Attendance Sheet duly signed by concerned faculty must be handed over to the Assessors.

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 8

27. REMARKS OF ASSESSOR

1. Please DO NOT repeat information already provided elsewhere in this form.

2. Please DO NOT make any recommendation regarding grant of permission/recognition
3. Please PROVIDE DETAILS of irregularities that you have noticed/ come across, during the assessment, like
fake/dummy faculty, fake/ dummy patients, fabrication/ falsification of data of clinical material etc. if any.

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 9

PART – I
(INSTITUTIONAL INFORMATION)

1. Particulars of Director / Dean / Principal:

(Whosoever is the Head of the Institution)

Name: _________________________________ Age: _ _ _ (Date of Birth) _ _ /_ _ /_ _ _ _.

PG Degree Subject Year Institution University

Recognized (or)
Not Recognized

Teaching Experience

Designation Institution From To Total experience

Assistant Professor
Assoc Professor/Reader
Professor
Any Other Grand Total

2. Central Library

a) Total number of Books in library: ____

b) Books pertaining to Dermatology: ____
c) Purchase of latest editions of books in last 3 years: Total: _ _ _ Dermatology books: _ _ _ .
d) Journals:
Total number Dermatology
Indian
Foreign

e) Year / Month up to which latest Indian Journals available: _______.

f) Year / Month up to which latest Foreign Journals available: _ _ _ _ _ _ _.
g) Internet: Available / Not available
h) Library opening times: _________________.
i) Reading facility out of routine library hours: Available / Not available
(Obtain a list of books & journals related to Dermatology duly signed by Dean)

3. Casualty/ Emergency Department

Particulars Numbers / relevant details

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

Equipment available

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FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 10

Blood Bank

(i) Valid License Yes / No Verified / Not verified

(ii) Blood component facility available Yes / No Verified / Not verified
(iii) All Units tested for Hepatitis C, B, HIV Yes / No Verified / Not verified
(iv) Nature of Storage facilities (as per specifications) Yes / No Verified / Not verified
(v) Number of Units available on Assessment day Verified / Not verified

(vii) Average number of units utilized daily and on the day of the assessment in the entire
hospital (various specialty wise distribution)

Average daily utilization Utilization on the day of assessment Verified / Not verified

4. Central Research Lab: Yes/No

a) Administrative control:
b) Staff:
c) Equipment:
d) Workload:

5. Central Laboratory (if any):

− Controlling Department:
− Working Hours:
− Investigative workload: (Approximate number of investigations done daily in entire hospital).

6. Central supply of Oxygen/Suction: Available / Not available

7. Central Sterile Supply Department Adequate / Not adequate
8. Bio-Medical Waste Disposal Outsources / any other method
9. Generator facility: Available / Not available
10. Medical Record Section: Computerized / Non computerized
− ICDX classification Used / Not used
11. Recreational facilities: Available / Not available

13. Hostel accommodation:

UG PG Interns
Detail
Boys Girls Boys Girls Boys Girls
Number of Students
Number of Rooms
Status of Hygiene/Cleanliness

14. Residential accommodation for Staff / Paramedical staff: Adequate / Inadequate

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 11

15. Ethics Committee (Constitution):

16. Medical Education Unit (Constitution)

(Specify number of meetings held annually)

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 12

PART – II
(DEPARTMENTAL INFORMATION)
1. Department inspected: Dermatology, Venereology & Leprosy (DVL).
2. Particulars of HOD

Name: _________________________________ Age: _ _ _ (Date of Birth) _ _ /_ _ /_ _ _ _.

PG Degree Subject Year Institution University

Recognized (or)
Not Recognized

Teaching Experience

Designation Institution From To Total experience

Assistant Professor
Assoc Professor/Reader
Professor
Any Other Grand Total

3. Purpose of Present Assessment: Grant of Permission/ Recognition/ Increase of seats /

Renewal of recognition/Compliance Verification
4. Date of last MCI/NMC Assessment of the department: __________________________
(Write Not Applicable for first NMC Assessment)
5. Purpose of Last Assessment: _________________________________________________
6. Result of last Assessment: ___________________________________________________
7. Mode of selection (actual/proposed) of PG students:

8. If course has already started, year-wise number of PG students admitted, and number with
names of available PG teachers in the department during the last 5 years:

No. of PG students admitted

Year Number and Names of PG Teachers available
Degree Diploma

9. Departmental General facilities:

Total number of Beds:

Total number of Units:
Unit wise staff details: Teaching faculty Residents

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY) - V_2020 13
10. Unit wise Teaching and Resident Staff: UNIT:_ _ _ _ _ _ Bed Strength: _ _ _ _ _ _
Full time/ PAN No./
Name & Date Experience Signatures
No. Designation part time/ TDS PG Qualification
of Birth Date wise teaching experience with designation & Institution (Faculty)
Honorary deducted
Subject/ Institution University Designation Institution From To Total * Whether benefit of
Year of Mentioning subject Period publications given
passing Yes/No – List papers

Note:
i. Unit wise Teaching/Resident staff should be shown separately for each unit in the proforma.
ii. FILL ALL COLOUMNS. Do NOT modify any part of the above table. Tampering with the format of the table will render your submission invalid.
iii. If BENEFIT OF PUBLICATIONHAS BEEN GIVEN, list only original articles in indexed Journals published during the period of assessment for promotion here. Annexure will NOT be considered.
iv. In case of persons with DNB qualifications, the name of the hospital/institution where DNB training was obtained and the year of passing should clearly be mentioned failing which she/he shall NOT be
considered. Merely mentioning National Board of Examinations, New Delhi shall not suffice.
v. Experience of Defense services personnel must be supported by certificate/s from the competent authorities of the office of the DGAFMS, to be attached with the Faculty declaration forms failing which it
shall not be considered.

I have verified the eligibility of all faculty members for the posts they are holding based on experience certificates issued by competent authorities of their place of working. The details of
their working and teaching experience while holding different Designations is furnished in the table above.

Institutional TAN No:

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY)- V_2020
14

11. Have any of these faculty members been considered in PG/UG Assessment at any other colleges
or for any other subject in this college or other colleges in the last 2 years? If yes, give details.

Date of assessment Subject Institution

12. List of Departmental Faculty members appointed / relieved after the last Assessment:

Names of faculty members

Designation Number
Appointed Relieved
1. Professor
2. Associate Prof.
3. Assistant Prof.
4. SR/Tutor/Demons.
5. Others

13. List of Non-teaching Staff in the department:

Sl.No. Name Designation

14. Departmental Library:

Total No. of Books

Purchase of latest editions in past 3 years
Number of Journals

15. Departmental Research Lab.

Space
Equipment

Research projects utilizing Research lab 1.

2.
3.

16. Departmental Museum (Wherever applicable).

Space
Number of specimens
Number of charts / diagrams

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY)- V_2020
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17. Clinical investigative workload and clinical material of the department (past 3 years):

Particulars Year 1 Year 2 Year 3

Total number of patients in OPD
Total number of patients in IPD
Weekly clinical work load for OPD
Weekly clinical work load for IPD
Skin Biopsies
Electro Surgical Procedures
ACNE surgery
Cryo Surgical Procedures
Chemical Peels
Skin grafting procedures
Intralesional injections
KELOID treatment
Nail Surgeries
NUVB/PUVA therapy
Laser Procedures
- Hair reduction
- Scar revision
- Pigment removal
Other cosmetic surgical procedures
Average daily consumption of blood units
(Past year)

18. Specialty clinics run by the department of DVL with number of patients in each:

Number of Name of Clinic

Name of the Clinic Weekday/s Timings
cases (Avg) In-charge
1) Vitiligo Clinic
2) Psoriasis Clinic
3) Autoimmune disease clinic
4) Vesiculobullous diseases
5) Hansen’s clinic
6) STD Clinic
7) Pigmentary Clinic
8) Any other

Separate examination and treatment room for STD patients: Available / Not available

19. Services provided by the department of DVL:

Service Availability Service Availability

Skin Biopsies Yes / No KELOID treatment Yes / No
Electro Surgical Procedures Yes / No Nail Surgeries Yes / No
ACNE surgery Yes / No NUVB/PUVA therapy Yes / No
Cryo Surgical Procedures Yes / No Laser Procedures - Hair reduction Yes / No
Chemical Peels Yes / No - Scar revision Yes / No
Skin grafting procedures Yes / No - Pigment removal Yes / No
Intralesional injections Yes / No Other cosmetic surgical procedures Yes / No

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY)- V_2020
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20. Space

Space / Area OPD IPD

Number of Rooms
Patient examination arrangements
Equipment
Teaching areas
Waiting area for patients

21. Office Space / Accommodation:

Department Office
Space (Adequate) Yes/No
Staff (Steno /Clerk) Yes/No
Computer/ typewriter Yes/No
Storage space for files Yes/No
Telephone / Intercom Yes/No

Office Space for Teaching Faculty*

Head of the Department Yes/No / Inadequate
Professors Yes / No / Inadequate
Associate Professors Yes / No / Inadequate
Assistant Professor Yes / No / Inadequate
Residents Yes / No / Inadequate
* Strike out whichever are not applicable

22. Clinico-Pathological Conferences (CPCs) participation: Yes / No

(If yes, provide numbers with dates)

23. Death review meetings: Yes / No

(If yes, provide numbers with dates)

24. Participation in National Leprosy Control Program, RTI/AIDS program/Others.

(List details here)

25. Details of data being submitted to Govt. / National authorities, if any:

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FORM-NMC- 2-PG (DERMATOLOGY)- V_2020
17

26. Equipment: List of important equipment* available and their functional status.
(Please fill out the details of the list here below. NO annexure to be attached)

Equipment Numbers / functional status / comments

1) Biopsy punches
2) Hyfrecator/electro-surgical instrument
3) Patch testing kits
4) Liquid nitrogen cyro
5) Chemical Peels
6) PUVA Chamber (total body)
7) NBUV Chamber
8) Laser for hair reduction
9) Laser for scar revision
10) Laser for pigment removal
11) Pulse Oxymeters
12) Syringe pump
13) ECG
14) Crash cart
15) Other routine equipment
16) Any other special equipment

27. Academic activities (outcome based):

a) Theory classes taken in the past 12 months

a) Numbers
b) Dates and subject Available & Verified / Not available
c) Name and Designation of the Teacher Available & Verified / Not available
d) Attendance sheet Available & Verified / Not available
b) Clinical seminars in the past 12 months
a) Numbers
b) Dates and subject Available & Verified / Not available
c) Name and Designation of the Teacher Available & Verified / Not available
d) Attendance sheet Available & Verified / Not available
c) Journal clubs conducted in the past 12 months
a) Numbers
b) Dates and subject Available & Verified / Not available
c) Name and Designation of the Teacher Available & Verified / Not available
d) Attendance sheet Available & Verified / Not available
d) Tutorials held in the past 12 months
a) Numbers
b) Dates and subject Available & Verified / Not available
c) Name and Designation of the Teacher Available & Verified / Not available
d) Attendance sheet Available & Verified / Not available

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FORM-NMC- 2-PG (DERMATOLOGY)- V_2020
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e) Group discussions held in the past 12 months

a) Numbers
b) Dates and subject Available & Verified / Not available
c) Name and Designation of the Teacher Available & Verified / Not available
d) Attendance sheet Available & Verified / Not available
f) Guest lectures organized in the past 12 months
a) Numbers
b) Dates and subject Available & Verified / Not available
c) Name and Designation of the Teacher Available & Verified / Not available
d) Attendance sheet Available & Verified / Not available

28. Any other information.

Signature of Dean Signature of Assessor

FORM-NMC- 2-PG (DERMATOLOGY)- V_2020
19

PART III
(POSTGRADUATE EXAMINATION)
(Only at the time of recognition Assessment)

1. Minimum prescribed period of training:

Date of admission of the Regular Batch appearing in examination: _ _ /_ _ /_ _ _ _

2. Minimum prescribed essential attendance:

3. Whether periodic performance appraisal is carried out:

4. Whether the candidates appearing in the examination have submitted their thesis six months before
appearing in examination as per PG Regulations2000:

5. Whether the thesis submitted by the candidates appearing in the examination been accepted:

6. Whether the candidates appearing in the examination have:

a) presented one poster Yes / No
b) presented a research paper at a National/State conference Yes / No
c) published / received acceptance for a paper during their PG study period Yes / No
d) communicated a paper for publication. Yes / No

7. Provide details of examiners appointed by Examining University below (No Annexures):

8. Whether appointment, eligibility of examiners and conduct of examination is as per prescribed

NMC/MCI norms: Yes / No

If not, provide details:

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

10. Year of passing out of the 1stbatch of PG students (mention name of previous/existing University)

Degree Course ------------------

Note:
i. Retired/Superannuated/re-employed faculty members should not be appointed as External Examiner.
ii. There should be two internal and two external examiners.
iii. Three external examiners should be appointed if two internal examinersare not available inthe department.

Signature of Dean Signature of Assessor