STANDARD ASSESSMENT FORM-A/2024 1

POST-GRADUATE MEDICAL EDUCATION BOARD

NATIONAL MEDICAL COMMISSION

STANDARD ASSESSMENT FORM-A

(Institutional Information Common for all PG Specialities)

INSTITUTIONAL INFORMATION
Name of Institution: ________________________________________________
Government/ Non-Government: _________________________________________
Standalone PG: Yes/ No
Period: ______________ to _______________
Date of the Report: ______________________
INSTRUCTIONS TO DEAN/ DIRECTOR/PRINCIPAL & HEAD OF THE DEPARTMENT
1. This Standard Assessment Form is meant for the purpose of giving Annual Disclosure Report
(Annual Self-Declaration) by Medical Colleges/Institutions as required under Section 4 of
MSMER-2023 regulation and for the Assessment/Inspection of a medical college/an institution by
the Assessor. It will be in Three Parts:
i. Form-A is for the Institutional Information and is common for all PG Specialities.
ii. Form-B is for Speciality specific information (Broad/Super Speciality).
iii. Faculty, Senior Resident and Post-Graduate Students Declaration Forms.
2. These Forms will be updated/modified from time to time. Please download it afresh at the time of
any application/submission.
3. For the purpose of Annual Disclosure Report (Annual Self-Declaration), the Data of previous year
(1st January to 31st December) will be considered.
4. Medical college/institution will fill up all the details/data. The Assessor will verify availability and
functional status of major infrastructure and major equipment of the institution mentioned in Form-
A and may verify the relevant workload data furnished by the medical college/institution as per the
requirement. Assessor will verify in detail all the items mentioned in Form-B (Department Specific
form).
5. The original copy of the Annual Self-Declaration Form shall be preserved by the medical colleges.
The PDF copy of SAF will be sent by e-mail.
6. Please read the FORM carefully before filling it up. Retrospective changes in Data will not be
allowed.
7. Do NOT edit or modify any part of the Form. Tampering with the format of this Form will render
your submission invalid.
8. Write N/A where it is not applicable. Write ‘Not Available’, if the facility is not available.
9. Head of the Department and Dean will be responsible for filling all columns and signing on all pages
and at the end of the Form. Do NOT leave any section of the Form or part thereof unanswered.
Incompletely filled up Form shall be summarily rejected.

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STANDARD ASSESSMENT FORM-A/2024 2

10. Dean, Head of Department (HoD) and Faculty should be thoroughly well-versed with all
Regulations and MSRs of NMC.
11. All Faculty, Senior Residents and Post-Graduate students will fill up the respective Declaration
Forms. It should be countersigned by HoD and Head of the institution. The original Declaration
Form shall be preserved by the medical colleges/institutions.
12. Medical College shall maintain the Declaration Forms who are relieved or retired during the
reported year.
13. Add rows in a Table as per requirement.
14. Non-compliance/wrong declaration or fake documents will invite penalties as per NMC regulations.
15. The working days will be calculated as per the following formula [365 – 52 (Sundays) –Holidays
declared by the respective Government/medical college]. The dates of the Holidays to be provided
by the medical college/institution as Annexure.
16. Annual detail of all clinical workload/ investigations will be provided as per the Data Table as and
when asked for. Template of the Data Table is at end of this document.

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STANDARD ASSESSMENT FORM-A/2024 3

A. GENERAL INFORMATION OF MEDICAL COLLEGE/ INSTITUTION

1. Name of Medical College/Institution: ________________________________

2. College Type: Government/ Non-Government: ________________________________

3. Stand-alone PG: Yes/No

4. LOP date of establishment of undergraduate college: _______________________________

5. Dates of the Holidays of last year. Attach file as Annexure.

6. Total working days of last year: _________________________________________

7. College Address: ____________________________________________

College City/Town: ____________________________________________

College District: ____________________________________________

College State: ____________________________________________

Pin Code: ____________________________________________

8. College Website: ____________________________________________

9. College E-mail ID: ____________________________________________

10. College Landline No.: ____________________________________________

11. College Mobile/Phone No.: ____________________________________________

12. College Competent Authority: Dean/ Director/ Principal

13. College Competent Authority Name: ___________________________________

14. College Competent Authority E-mail ID: ___________________________________

15. College Competent Authority Mobile No: ___________________________________

16. College Competent Authority Landline No: ___________________________________

17. Name and Address of Affiliated University: ___________________________________

18. Name and address of the Vice-Chancellor: __________________________________

19. Landline No./Mobile No of the Vice-Chancellor.:______________________________

20. E-mail address of the Vice-Chancellor: _____________________________________

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B. DETAIL OF UNDERGRADUATE MEDICAL COLLEGE/INSTITUTE:

Total number of UG seats: ______________

Total hospital beds of all Departments required for UG College: _____________

Parameter On the day of Year 3

Year 1 Year 2
Assessment (Last Year)
(1) (2) (3) (4) (5)
Total OPD patients of
all departments
required for UG
college
(Write the average of
all the OPD days in a
year in column 3, 4, 5)
Bed Occupancy of all
the required In-patient
beds for UG College.
(Write average of all
days in a year in
column 3, 4, 5)

C. LIST OF ALL BROAD SPECIALITY AND SUPER SPECIALITY DEPARTMENTS

EXISTING IN THE INSTITUTION WITH BASIC DETAILS:

Name of Department Total Beds Total No. of Total No. of Year of

Units Admissions Starting the
per year Course

D. COMMON INFRASTRUCTURE:

I. General:
Parameters Availability Adequate/ Not
Adequate
Central supply of Oxygen Yes/No

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Central Suction Yes/No

Central Sterilization Department Yes/No

Laundry Yes/No
Kitchen Yes/No
Generator facility Yes/No
Bio-waste disposal Yes/No
Computerized Medical Record Section Yes/No
Which ICD classification being used ICD10/ICD11

II. Out-Patient Department:

Space and arrangements : Adequate/Not Adequate

Parameter On the day of Year 3
Assessment Year 1 Year 2 (Last
Year)
(1) (2) (3) (4) (5)
Total OPD Patients of all the
Departments in the hospital
(Write the average of all the OPD days
in a year in column 3, 4, 5)

III. Blood Bank:

License valid till date: _______________________________

Blood component facility: Available/Not Available

Parameter On the day Year 3

of Year 1 Year 2 (Last
Assessment Year)
(1) (2) (3) (4) (5)
Blood Units including Components
issued
Blood Units including Components
utilized in the hospital (write
average of all days in column 3,4,5)
Average number of units utilized
daily by the various Specialities
(Attach Annexure)
Blood units collected
Total Number of Cross matchings

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Number of units stored

(write average of all days in column
3,4,5)
Number of Units available on
X X X
Assessment Day

IV. Emergency Department/ Casualty Services

Number of Beds (Exclude beds in the Triage area): __________________

a. Equipment:

Name of the Numbers Functional Important Specifications in brief

Equipment Available Status
Ventilators
Defibrillators
Fully equipped
disaster trolleys
Multipara monitors
Dedicated portable
x-ray machine
available:
Number of
Ambulances
Ultrasonography
with color Doppler
and curvilinear
probe, Linear
probe, and Phased
array
probe(cardiac)

b. Specific Clinical/ Investigative Workload of the Emergency Department:

On the Year 3
day of Year 1 Year 2 (Last
Particulars Assessm Year)
ent

1 2 3 4 5
Number of patients attended (in the green
zone/ OPD of the Emergency
Department) for OPD workload.
(Write average daily attendance in
columns 3, 4 and 5*)

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On the Year 3
day of Year 1 Year 2 (Last
Particulars Assessm Year)
ent

Admissions (number of patients admitted

in Red and Yellow Zones).
(Write average daily admission in
columns 3, 4 and 5*)
Total number of patients admitted in the
hospital through EM Deptt.
Bed occupancy for Percentage of Bed X X X
Occupancy
Bed occupancy for the whole year above X Yes/No Yes/No Yes/No
75% (Prepare a Data Table)

Number of Major surgeries for patients

attending EM#
Number of Minor Surgery/Procedures in
EM @

Details of the Procedures

(Give the details in the Table given
below)
Consumption of blood units for EM
patients (Write average of all 365 days in
column 3,4,5)
X-rays per day for EM patients
(Write average of all 365 days in column
3,4,5)
Ultrasonography per day for EM patients
(Write average of all 365 days in column
3,4,5)
CT scans per day for EM patients
(Write average of all 365 days in column
3,4,5)
MRI scans per day for EM patients
(Write average of all 365 days in column
3,4,5)
OPD Haematology workload per day for
EM patients
(Write average of all 365 days in column
3,4,5)
OPD Biochemistry workload per day for
EM patients

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On the Year 3
day of Year 1 Year 2 (Last
Particulars Assessm Year)
ent
(Write average of all 365 days in column
3,4,5)
OPD Microbiology workload per day for
EM patients
(Write average of all 365 days in column
3,4,5)
ABG per day for EM patients
(Write average of all 365 days in column
3,4,5)
Cardiac biomarkers per day (average)
for EM patients
Total deaths in the EM Department

* Average daily attendance is calculated as below.

Total patients attending EM in the year divided by total number of days in a year

# Total number of major surgeries of patients shifted to Hospital/Operating Room directly

from ED or are operated in the ED Operation Theatre.

@ Minor Operation can be those that are done in the Procedure Room /Minor Operation
Room inside the ED. These may include wound wash/debridement in the ED, wound
suturing or removal, K-wiring, dislocation reduction, etc.

Details of Procedures

Procedures On the day (Last Year)

of
Assessment
Central Line placement

Non-invasive ventilations

Pleural Tapping/Chest tube insertion

Pericardiocentesis
Cardioversion/Defibrillation
Incision and Drainage of abscess

Endotracheal Intubation with direct

laryngoscopy
Major trauma primary care like
splinting/dressing

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Endotracheal intubation with video

laryngoscopy
Tracheostomy

Ultrasonography

Transcutaneous Pacing

Regional Block

V. Intensive Care Facility:

Total intensive care unit beds in hospital: ________

Total and high dependency beds in hospital: ________
Total Post-operative/ Post Anaesthesia care unit beds in hospital: _________

Intensive care facilities:

Type Managed by Number List of Major Equipment Bed Average
which of total and their Numbers occupancy on bed
Department beds the day of occupancy
Assessment for the last
year
Medical ICU- MICU

Surgical ICU – SICU

Neonatal ICU- NICU

Paediatrics ICU- PICU

Intensive Coronary
Care Unit – ICCU
Critical care unit-CCU

Any other ICU (add

rows)

VI. Dialysis:

a. Number of Beds: ________________

b. Number of Hemodialysis Machines: ________________

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On the Year 3
day of Year 1 Year 2
(last year)
assessment
Total Hemodialysis
Total Peritoneal Dialysis

VII. Radiology Department:

a. Equipment:

Sl. Name of the Numbers Functional Important Specifications in brief

No. Equipment Available Status

1. X-Ray Machines-
Static
i.
ii.
iii.
2. X-Ray Machines-
Portable
i.
ii.
iii.
3. X-Ray Machines-
TV/Imaging facility
4. CT Scan (Mention
slices, year of
manufacturing with
other
specifications)
i.
ii.
5. MRI (Mention
Tesla, year of
manufacture with
other
specifications)
6. USG – Grey Scale
(mention probes
available with each
machine)
i.
ii.
iii.
7. USG – Colour
Doppler (mention

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STANDARD ASSESSMENT FORM-A/2024 11

probes available
with each machine)
i.
ii.
iii.
8. Mammography
9. DSA
10. Any other
equipment (add
rows)

b. Clinical workload of the Radio-diagnosis Department:

Parameter On the day Year 3
of Year 1 Year 2 (Last
assessment Year)
(1) (2) (3) (4) (5)
Total Plain X-rays (write average of all working
days in a year in column 3, 4, 5)
IVP
Barium Swallow
Barium Upper GI studies
Barium Meal Follow through
Barium Enema
HSG
Silography
Urethrogram
MCUG
Fistulography/Sinography
Total Number of Ultrasonography
Number of Ultrasonography
(write average of all working days in a year in
column 3, 4, 5)
Doppler studies for abdominal vessels and scrotal
conditions
Doppler study for peripheral vessels
Doppler study for carotid vessels
Other Doppler studies
USG Guided procedures-FNAC/ Biopsy
USG Guided procedures –aspiration/intervention
Total CT scan

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Parameter On the day Year 3

of Year 1 Year 2 (Last
assessment Year)
(1) (2) (3) (4) (5)
Total CT scan per day
(write average of all working days in a year in
column 3, 4, 5)
Number of plain CT Scans (without contrast)
Number of plain CT Scans Brain
Number of plain CT Scans Abdomen
Number of plain CT Scans Head and Neck
Number of CT contrast Enterography
Number of CT contrast Urography
Number of CT contrast Enema
CT guided procedures like FNAC/BIOPSY
Total MRI
Total MRI per day
(write average of all working days in a year in
column 3, 4, 5)
Number of plain MRI (without contrast)
Number of plain MRI Brain
Number of plain MRI for spine
Number of MRI with contrast
Number of MR Urography
Number of MR Cholangiopancreatography
Mammography
Angiography (Conventional)
Angiography (DSA)
Any others (Please add rows)

VIII. Pathology Department

a. General Information:

Spacing and Organization of Adequate / Inadequate

Laboratories:
Laboratory Management Information Available / Not Available
System:
Internal Quality Assurance Practiced: Yes/No

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External Quality Assurance Services Yes/No

Practiced:
If yes, details of EQAS
Lab Accredited: Yes/No
If Yes Give Details

b. Equipment:
Name of the Numbers Functional Important Specifications in brief
Equipment Available Status

Binocular Microscopes
Penta head Microscope
Binocular Research
Microscope with
photography facility
Automated Tissue
Processor
Microtome
Cryostat for Frozen
Sections
Microwave for IHC
Cell Counter
HPLC Machine (Hb
variants)
Centrifuge / Cytospin
PT and Aptt Automated
Analyzer/Coagulomete
r
Flowcytometry for
Hematology
IHC equipment
Any other equipment
(Add rows)

c. Details of different sections in the Department of Pathology:

Section Area (M2) Equipment available
Histopathology
Cytology / Cytopathology
Hematology
Fluid section
Autopsy/ Morbid Anatomy
Other

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d. Clinical workload of the Pathology Department:

On the day
Year 3
Nature of Specimens of Year 1 Year 2
(Last Year)
Assessment
(1) (2) (3) (4) (5)
Total number of histopathology
investigations [(Total specimens
(Organ/Part/Tissue)] for
histopathology received and
reported *
Frozen sections
Special stains (give details below in
brief)
Immunohistochemistry (mention
below if outsourced)
Total Hematology Specimen
received and tested
Total Cytopathology Specimen
received and reported
(Cytopathology workload)
Fluid Cytology
Exfoliative Cytology
FNAC (Direct)
FNAC (CT guided)
FNAC (USG guided)
PBF
Bone marrow

e. Histopathology

Types of histopathological reports by the Department of Pathology:

Nature of Disease On the day

Reported Year 3
of Year 1 Year 2
(Last year)
Assessment
Tuberculosis
Other infections/
Inflammations
Benign/Non Neoplastic*
Malignancies
Others (specify)
Note: * Tuberculosis and Other infections/inflammations to be excluded here.

f. Hematology:
i. Total Hematology samples received and tested: ________
ii. Number of Investigations:

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Total Numbers
Name of test
Number on Year 1 Year 2 Year 3
day of (Last Year)
Assessment
CBC
ESR
Reticulocyte Count
Absolute Eosinophil Count
Bone Marrow Aspiration
Bone Marrow Biopsy
PT, Aptt, TT

iii. Facilities for the work up of the following (Name of investigation & numbers per year):
Name of the Test Number on Year 1 Year 2 Year 3
day of (Last Year)
Assessment
Coagulation Disorders
Leukemia
Nutritional Anemias
Hemolytic Anemias

g. Body Fluids (Clinical Pathology):

Name of the Test Number on Day Year 1 Year 2 Year 3
of Assessment (Last Year)
Urine: Routine
Urine Special:
Semen: Routine
Semen: Special
CSF
Sputum:
Other body fluids:

IX. Biochemistry Department

a. General Information:

Spacing and Organization of Adequate / Inadequate

Laboratories:
Laboratory Management Information Available / Not Available
System:
Internal Quality Assurance Practiced: Yes/No

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External Quality Assurance Services Yes/No

Practiced:
If yes, details of EQAS
Lab Accredited: Yes/No
If Yes Give Details

b. List of Department specific laboratories (e.g., undergraduate laboratory, postgraduate

laboratory etc.) with important Equipment (if applicable):
Laboratory Equipment Functional Status

UG Laboratory As Per UGMSR2023

PG Laboratory 1. Electrophoresis
2. Chromatography
3. Spectrophotometer
4. Semi / Auto Analyzer
5. Electrolyte Analyzer
6. ELISA

Clinical Chemistry 1. Semi Auto Analyzer

Laboratory in Hospital 2. Fully Auto Analyzer

Immunochemistry 1. Immunochemistry
Analyzer
2. CLIA

c. Clinical material and investigative workload of the Department of

Biochemistry:
No. of samples received: __________
No. of Tests Done: ----------------------

i. Clinical chemistry Investigations:

On the day of Year 3 Daily Average

Investigations Assessment Year 1 Year 2 for the Last
(Last Year) Year
Glucose
Urea
Creatinine
Serum
bilirubin
Serum
proteins

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Electrolytes
Lipid profile
Calcium
Magnesium
Phosphorus
Uric acid
Urine analysis
Pleural fluid
CSF
Peritoneal
Fluid
Any other

ii. Special investigations including enzymes, chemiluminescence and immunochemistry

On the day of Daily Average

Investigations assessment Year 1 Year 2 Year 3 for the last
year
Serum Amylase
Serum Lipase
Serum AST
Serum ALT
Serum ALP
Others
Hormonal
Assays
Thyroid
Hormones
Steroid
Hormones
Sex Hormones
Other
Vitamins Assay
Iron Profile
HbA1C
Ferritin
CRP
Tumor markers

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Immunoglobulin
Assays
Troponins
Others

X. Microbiology Department

a. General Information:

Spacing and Organization of Adequate / Inadequate

Laboratories:
Laboratory Management Information Available / Not Available
System:
Internal Quality Assurance Practiced: Yes/No

External Quality Assurance Services Yes/No

Practiced:
If yes, details of EQAS
Lab Accredited: Yes/No
If Yes Give Details

b. Equipment:
Name of the Numbers Functional Important Specifications in brief
Equipment Available Status
Binocular Microscopes
Fluorescence
Microscope
Inverted Microscope
Multi-header
Microscope
BOD Incubator
Bacterial Incubator
Hot Air Oven
Autoclave
Centrifuge
Anoxomat / McIntosh
Fildes Jar
pH Meter
Electronic Weighing
balance
Candle Jar
VDRL Shaker/ Rotator
ELISA Washer

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Name of the Numbers Functional Important Specifications in brief

Equipment Available Status
ELISA Reader
LCD screens
Deep Freezer -200
C Deep Freezer -800
Laminar Flow
Horizontal
Laminar Flow Vertical
Biosafety Cabinet BSL2
Digital Water Bath
Automated Blood
Culture
RT (Real Time) - PCR
Conventional PCR
GeneXpert
CLIA
(Chemiluminescence-
Immunoassay)
Any other equipment

c. Total number of Laboratories in the Department:

Name of the Available General List of Essential equipment
Laboratory (Yes/ No) Facility
(Adequate/ Not
Adequate. If not
adequate, mention
the deficiencies)
Bacteriology
Serology/ Immunology
Virology
Mycology
Parasitology
Mycobacteriology
STI Lab
Anaerobic
Media Room
Hospital Infection
Control Testing
Facility & Record
keeping
ICTC
DOTS

d. Year-wise workload (past 3 years) for the entire hospital:

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On the day of Year 3

Particulars Year 1 Year 2
assessment (last year)
Bacteriology
Serology/ Immunology
Mycology
Parasitology
Virology
Molecular tests
Any others

XI. Obstetrics and Gynecology Department

a. Infrastructure
1. Total beds in Department
2. Total operation theatres in the Department.
3. Number of delivery tables
4. No of beds in Eclampsia room with Multipara
monitors, CTG and infusion pumps on each bed

b. Equipment:
Name of the Equipment Numbers Functional Important Specifications
Available Status in brief
Multiparameter Monitors
Pulse Oxymeters
Infusion pump
CTG Machines
No of USG machines with Doppler
facility and TV probe and convex
probe–
(Should have minimum 2 machines)

c. Workload
Deliveries: (Total) On the day of Year 3 (Last
Year 1 Year 2
Assessment year)
Normal (Vaginal)
Operative (Vaginal)
Operative (CAESAREAN)
Deliveries including LSCS per X
week

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(average of all weeks of the year)

XII. Operation Theatre:

a. Total number of Operation Theatres with anesthesia facilities in whole hospital: __________
b. Do you fulfil the operational guidelines for Operation Theatres Complex prepared by the
Ministry of Health and Family Welfare? [Link:
https://nhsrcindia.org/sites/default/files/Guidelines-on-OT.pdf ]: Yes/No.
If No then mention deficiencies and what measures are you taking to fulfill those deficiencies.
(Annexure)

On the day of Year 3

Particulars Year 1 Year 2
Assessment (Last year)
Total number of Major surgeries
performed in all disciplines of the
institute of entire hospital
Total number of Minor
operations of entire hospital of all
departments)

c. List of Common Major Equipment in Operation Theatres:

Name of the Equipment Numbers Functional Important Specifications in
Available Status Brief

XIII. Facilities for PG Students:

a. Separate Rest Room/Duty room for Male and Female students: Available/Not Available
b. Hostel Accommodation for PG students:
List No. of Rooms available with
attached Bath
S.No. Details Number Boys Girls
i. Total PG seats (Broad Speciality + Super
Speciality):
ii. Total required Senior Residents for
Broad Speciality:
Option of installation of air conditioner available: Yes/No

c. Recreational Facilities:
Details Available/ Not Available Used regularly/not used
Playground with outdoor
sports facility like cricket,
football, basketball etc.

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Gymnasium with indoor

sports facilities like table
tennis, badminton etc.

d. Stipend paid to the PG students, Year-Wise:

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

e. Anti-Ragging Committee Members (attach file as Annexure):

f. Number of Anti-Ragging Committee Meetings held in the year:

g. Whether Annual Report pertaining to Anti-Ragging Regulation Submitted: Yes/No

XIV. Medical Record Section

a. Organization of the Medical Record Section:

b. Staff:
c. Details of the Software Available:

XV. Central Library

a. No. of books and Journals: Adequate/Not Adequate
b. Reading Room Facility: Adequate/Not Adequate

E. COMMON ACADEMIC ACTIVITIES:

a. Ethics Committee Details:

i. Ethics Committee Members (Annexure)

ii. Registration details:
iii. Number of Ethics Committee meetings held in the year (last year):

b. Medical Education Unit :

i. Committee members:
ii. Number of meetings held annually:

c. Numbers of Clinico-pathology Meetings held in last year:

d. Number of Death Review Meetings held in last year:

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e. Number of Infection Control Committee meetings held in last year:

F. DEATH:
Number of deaths
On the day of Year 1 Year 2 Year 3
Assessment (Last year)

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G. REMARKS OF THE ASSESSOR

(The Assessor may send the Confidential Remarks separately within 24 hours of the completion
of the Assessment/Inspection.)

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Annexure

DATA TABLE

(Clinical Workload of - )

Months January February March April May June July August September October November December
Date

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

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23
24
25
26
27
28
29
30
31

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