Any other matter which is required to be or may be prescribed by the State Government.
District Collector, Chandigarh and Chairperson of District Registering Authority U.T. for registration of clinical establishments in U.T.
Chandigarh;
2. Director Health and Family Welfare, U.T. C.handigarh; ----- ~PrihcipalMedical Officer, GMSH/16.C/:1andl h. ~ «;1 0(\\ \r') L- .~ , D\ ~ /' oint ecr.etary Health .
/ ~ Chandlgarh Administration /_ ~9\>1-1" ~ j ,1-1/11 t-4JJ-fa b'~ \)57/;( t f)" rI~ V·'·~ ! 0'-/ '-L\()L...' C!. \...... \..~"<\.: ,; \ ';) "r ~'r\'> o o 0" 0 Taluka: ..........,.. _ State: -=- Pin code _ Mobile: Fax;
Website (if an-y-=-):---------- SG1 Form Application Form for Provisional Registration of Clinical Establishments \
1. Name of the Establishment
2. Address: --------------------- ViIlagefTown: -'-_ District: .--::-:--===-_,...-;- _ Tel No (with STD code): _ EmaillD: _
3. Yearofsmrling: _
4. Location: 0 Rural 0 Urban 0 Metropolitan
5. Ownership Public Sector a Central government 0 State government a Local government- please specify:
o Public Sector Underlaking 0 Railways 0 Employee State Insurance Corporation (ESIC) o Autonomous organization 0 Any other (please specify):/ Private Sector o Individual Proprietorship 0 Registered Parlnership 0 Registered Company o Co-operative Society o Trust/Charitable registered under a Central, Provincial or State Act (please specify):
o Any other (please specify) ..· _
6. Name of the owner of Clinical Establishment: -,-- _ Educational Qualification: _ Address: -=:--:--:- _ VillagelTown.; --=-~--- Taluka: ----,------ District: State: ~------ Pin code _ Tel No (with STO code): Mobile: Fax: _ EmaillD --=-__--::----:--__~---::-::-_:___=_=;--:--:-:"::-:---:---------
7. Name ofperson In-charge of the Clinical Establishment: _ Designation: Educational Qualification: _ Address: -=---:--:- _ VillagelTown: Taluka: _ District: ----:-....,.--- State: Pin code _ Tel No (with STD code): Mobile: Fax: _ EmaillD:
8. Systems of Medicine offered: (please tick whichever is applicable) o AI/opathy 0 Ayurveda 0 Unani o Homeopathy 0 Yoga & Naturopathy o Siddha
9. Type of Establishment: (please tick whichever is applicable) Providing Out Patient Care o Single prac@oner 0 Polyclinic 0 Sub-Centre 0 Physiotherapy Clinic o Occupational Therapy 0 Inferlility 0 Dental clinic 0 Dispensary o Dialysis Centre 0 Integrated Counseling and Testing Centre (ICTC) o WeI/ness/fitness centre o Any other (please specify): _ '. Providing In Patient Care o Maternity Home o Community Health Centre o Hospital 0 Nursing Home o Primary Health Centre 0 Sanatorium o Any other (please specify): _ Providing Testing & Diagnostic Services:
Laboratory o Biochemistry o Collection Centre o Pathology 0 Haematology o Microbiology 0 Genetics o Any other (please specify):, _ Diagnostic and Imaging Centre o Bone Densitometry o CT Scan o X Ray centre 0 Mammography [J Sonography 0 Color Doppler o Magnetic Resonance Imaging (MRI) o Positron Emission Tomography (PET) Scan o Electro Myo Graphy (EMG) o Any other (please speciry): _ Any other (please specify): _
10. Nature of Services (please tick whichever is applicable) For all Systems of Medicine o Multi Specialtyo General 0 Single Specialty o Super Specialty 0 Mobile (J Any other, please specify:, _ a) Allopathy o General Practice 0 Out-patient (J In-patient o Day care centre 0 Emergency I Casualty 0 ICU o ICCU 0 Blood Bank 0 Organ /Tissue Bank o Special Care Services for challenged persons o Any other please specify: _ o Shodhan Chikitsa o Vyavastha b) Ayurveda o Ausadh Chikitsa 0 Shalya Chikitsa o Rasayana 0 Pathya o Any other please specify: _ c) Unani o Matab o Hifzan-e-Sehat o Jarahat 0 lIaj-bit-Tadbeer o Any other please specify: _ d) Slddha o Maruthuvam 0 Sirappu Maruthuvam 0 Varmam Thokknam & Yoga o Any other please specify: _ e) Homeopathy o General Homeopathy o Any other please specify;
f) Naturopiithy o External Therapies with natural modalities 0 Internal Therapies o Any other please specify: _ g) Yoga o please specify: _ INFRASTRUCTURE DETAILS
11. Area of the establishment (in sq. meters):
a) Total Area: b) Constructed area: _
12. OutPatient Department
13.1 Total no. ofOPO Clinics: _
13.2 Specialty-wise distribution of GPO Clinic Sr. No.
13. In Patient Department:
Specialty No. of Rooms
13.1. Total number ofbeds: ~--:-:----:--:__-----:-::__--------
13.2. Specialtywwise distribution ofbeds, please specify:
Sr. No. Specialty No. ofBeds
14. Whether Clinical Waste Disposal License obtained from Panchayat/Municipa/ity/Municipal Corporation etc?
DYes o No o .Applied For
15. Whether clearance from Pollution Control Board/Authority obtained?
DYes HUMAN RESOURCES o No o Applied For
16. Total number of Staff (as on date of,application):
No. of permanent staff: No. of temporary staff: _ Please furnish the following details:- Category of Name Qualification Registration Nature of Staff Number (where service applicable) Temporary/ Permanent Doctors Nursina Staff Paramedical Staff Pharmacists Cl Postal Order ISupport staff I I~:~~. please "Separate annexure may be attached.*
17. Payment options for Registration Fees:
Q Online payment Cl Demand Draft o Any other (please specify): _ Amount (in Rs): _ Details: -:-:- _ Receipt No. _ I,............... .. on behalf of myself and the company/society/associatlon/body hereby declare that the statements above are correct and true to the best my knowledge and I shall abide by all the rules and declarations under the Clinical Establishment (Registration and Regulation) Act 2010.
I undertake that I shall intimate to the appropriate registering authority any change in the particulars given above.
Place:
Date:
Signature of the Authorized Signatory Office Seal SG2Annexe ACKNOWLEDGEMENT REGISTRATION OF CLINICAL ESTABLISHMENT The application in Form for Grant I Renewal of Provisional I Permaryent registration of the Clinical Establishment submitted by _ (Name and address of Owner) has been received by the District Registering Authority on (date) and found to be Complete Or Incomplete This acknowledgement does not confer any rights on the applicant for grant or renewal of registration.
Signature and Designation of District Registering Authority or authorized person in the Office of the Authority.
SEAL Designation of the Issuing Authority (Computer Generated) Place & Date: (Computer Generated) .• SG 3 Annexa PROVISIONAL CERTIFICATE FOR REGISTRATION OF CLINICAL ESTABLISHMENT Provisional registration No: (Computer Generated) Date of issue: (Cotnwrter Generated) Valid up to: {Computer Generated)
1. Name of the Clinical Establishment: _
2. Address: --------------------------
3. Owner of the Clinical Establishment: _
4. Name of Person in Charge: _
5. System of Medicine: _
6. Type of Establishment: _ Is hereby provisionally registered under the provisions of Clinical Establishments (Registration and Regulation) Act 2010 and the Rules made there under.
This authorization is subject to the conditions as specified in the rules in force under the Clinical Establishments (Registration and Regulation) Act 2010 and the Rules made there under.
Designation of the Issuing Authority (Computer Generated) Place & Date: (Computer·Generated) District Registration Authority Address:
Phone number in case of Grievances SG 4 Annexe PERMANENT CERTIFICATE FOR REGISTRATION OF CLINICAL ESTABLISHMENT Permanent registration No: (Computer Generated) Date of issue: (Computer Generated) Valid u'p to: (Computer Generated)
1. Name of the Clinical Establishment: ----------------
2. Address:-------------------------
3. Owner of the Clinical Establishment _
4. Name of Person in Charge: _
5. System of Medicine: _
6. Type of Establishment: _ is hereby pennanently registered under the provisions of 'Clinical Establishments (Registration and Regulation) Act 2010 and the Rules made there under.
This authorization is sUbject to the conditions as specified in the rules in force under the Clinical Establishments (Registration and Regulation) Act 2010 and the Rules made there und~r.
Designation of the Issuing Authority (ComputerGenerated) Place & Date: (Comp~ter Generated) District Registration Authority Address:
Phone number in case of Grievances \ 5G 5 Annexe Fees to be charged (In rupees) Rural( out of Municipal Corporation's Urban ( within the Metro ( not applicable for limit} Municipal Corporation's the present as limit Chandigarh is not Metro city Out Patient Care Provisional Permanent Provisional Permanent Provisional Permanent 50 250 100 SOD 200 1000 In Patient Care 01 to 30 50 250 100 SOD 200 1000 Beds 30 to 100 100 500 200 1000 400 2000 Beds Above 100 150 650 300 1500 600 3000 Beds Testing & Diagnostic Labora- 100 SOD 200 1000 400 2000 tories Diagnostic 150 650 300 1500 600 3000 & Imaging Centre Other Fees: - • For Renewal half of the amount of registration fee (Provisional I Permanent} • For late application the amount would be double of the registration fee (Provisional / Permanent) • For duplicate Certificate the amount would be Rs. 200/- • For change of ownershIp management or name of establishment would be Rs. 100/- • For any appeal the amount would be Rs. 1000/-.
If a laboratory or diagnostic centre is a part of an establishment providing outpatient/inpatient care no separate registration is required.
· , SG 6 Annexa DUPLICATE CERTIFICATE FOR REGISTRATION OF CLINICAL ESTABLISHMENT Permanent registration No: (Computer Generated) Date of Issue: (Computer Generated) Valid up to: (Computer Generated)
1. Name of the Clinical Establishment: _
2. Address: _
3. Owner of the Clinical Establishment: _
4. Name of Person in Charge: _
5. System of Medicine: _
6. Type of Establishment _ is hereby provisionally I permanently registered under the provisions of 'Clinical Establishments (Registration and Regulation) Act 2010 and the Rules made there under.
This authorization is subject to the conditions as specified in the rules in force under the Clinical Establishments (Registration and Regulation) Act 2010 and the Rules made there under.
Designation of the Issuing Authority (Computer Generated) Place & Date: (Computer Generated) District Registration Authority Address:
Phone number in case of Grievances SG 7 Annexe Format for Submission of Inspection Report Number of visits made with dates Names and details of members of the inspection team Name of clinical establishment visited Address and contact details of clinical establishment visited Process followed for inspection (e.g. kindly outline who was met with, what records were examined, etc) Salient Observations I Findings Conclusions Specific Recommendations:
(1) To the Clinical Establishment
(2) To the District Registering Authority *In case of lack of consensus amongst members of the inspection team, the same may be kindly indicated Signature (of all members of the inspection team) Date Place SG-8 Annexe Application for ap'peal ( See 5.36(2) To The State Council Government of Sir, I, Dr of had applied for registration lis a valid license holder with registration number under Clinical Establishments Act, 2010 for my .Iocated at ..
I was communicated by the District Authority as per letter No dated that either;
il That my application as rejected ii) That my registration is cancelled iii) That I am restrained from carrying on with the running of clinical establishment tv) That I am charged with a penalty for an offence under the Act v) Any other.............. .
The above decision of the District Authority appears to be not valid. r request you to consider my application as per the justifications mentioned below:- i) ..
iI) ..
iii) ..
I am willing to appear before you for a personal hearing, if necessary. I am enclosing herewith a draft of Rs.l000/-, Thanking you, SIgnature Place:
Dated: Name:
~, u, A 'v , o'gureau \..IJ i"'I-I/~ I Gcf ""~"~Ye -.2/.!'." . . ?- '7;,·1· '?f,l.-, I'l/, r::J J.j,':>: I"~ f :,"-.l.{;. b - I.~ I ·"~~~""·-~-t.~ ~/i) 7" . ~ ,......../' "" "rft~ ~.,; 2'~E3-"-' - . ~)l:1i~!\r!.~ ....!:-,~+,,~.'.,..I..~~ ffl.'·-P ...."alluigClr'h ell inistra~lon G/(), D. H. ,'i, 1f:,·i,~lV. U.T.
" , br t--;--- Jt- Health Department C;J[!2!!i,ri)/lrh..
i; (I,k"'l ~:~/." ~~~/]~ Notification \1\/'1 f 01N~ .tJ\I'v') /,)/..\/1 Chandigarh, dated the January, 2013 No.3951/FII(5)/2013! }J I-- In exercise of the powers conferred by Section 10 ,*\I'J'b of the Clinical Establishments ( Registration and RegulatIon) Act, 20lO ( 23 of 2010) and all. other powers enabling him in this behalf, the Administrator, Union Territory, Chandigarh is pleased to set up District Registering AuthorIty, Union Territory, Chandigarh for registration of clinical establishments in the Union Territory ·of Chandigarh, consisting of the following:- l. District Collector, Cilandigarh ..Chairperson'
2. Senior Superintendent of Police Chandigarll Or his nominee .. Member ? Secretary Municipal Corporation,J.
Chandigarh. ..Member
4. Dr. Ramneel< Singh 13edi, President, Indian Medical Association, Chandigarh ..Member
5. Principal MediCtll Officer, GMSH/16, C11Clndigarh. ..Conv3lor Anil Kumar, lAS Secretary Health, Cllandlgarh Administration.
/-- Sllper;ntendent/Consullant(H) For Secretaiy Healtll, Chandigal'h Administration .
Endst. No. 3951/FII(S)/2013/ Dated, the January, 2013 A copy is forwarded to the Controllel, Printing and :,talioncr'{ Department; U.T. Cl1andlgarh with HIe request that the aforesaid notification may please be got published In the e~traordinary Gazette of Chandigarh Administration and supply 20 printed copies thereof for office use.
.,~ )07' 'End:,;t No. 3951/I=n (5)/2013/ Dated, the 2-2-'VI.d January, 2013 , A copy is forwarded to the following for informatIon and necessary- , action:-
1. District C~ctOl', Chandlgal'h
2. S~iorSUperinten(lent of Police, Chandigarh;
3. v15irector Health ~. Family Welfare, Union Territory, ChandigarlJ;
4·. Secretary, Municipal Corporation, Chcllldlgmh;
5. Dr. Ramneel< -Singh Bedi, President, Indian Meclical Association, Sector 35-A, Chandigarh;
6. Principal Medicf;l1 Officer, Chandigarh.
( ../I~- Superint~CO'\Sliltant(l-I) For Secretary Heal':l1, Chc)/ldigarh Administration.