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Maharashtra Nursing Council, Mumbai


Inspection Form from 20/07/2016
1. General Information
Name of the Institution
Full Address with Pin Code
Date of Inspection
Contact details
Head of the Institution
Telephone No
Mobile No.
E-mail id
Contact details of the Principal Telephone No
Mobile No.
E-mail id
Skype Account No
Name of Courses inspected ANM GNM
B. Sc. (N) P. B. Sc.(N)
M. Sc. (N) Other

Intake sanctioned Purpose of inspection


State Government Feasibility

Indian Nursing Council Periodical

Maharashtra Nursing Council Enhancement of seats

MUHS, Nashik Surprise

Deemed University Final Approval

Name and Signature of Principal with designation Name and Signature of Inspection
rubber stamp
(1) ___________________________
Place: Date:
(2) ___________________________
2

Standard Area
PARTICULARS as per INC
YES NO REMARKS
(For 40-60 admission capacity) specified
(in sq.ft)
2. Physical Infrastructure

A. Teaching Block 20,000

Class Rooms as per programme (Total No.) 900 each

Laboratories as per programme


1500
Nursing foundation Lab
900
CHN and Nutrition Lab
900
Advance Nursing Skill Lab
900
M.Ch.Lab
900
Pre-clinical science Lab
900
Computer Lab

Multipurpose Hall 3000

Library
Nursing Books (minimum 500)
Kinds of Nursing Journals 1800
Kinds of Newspapers
Kinds of Magazines

A.V. Aid room 600

Principal Office 300

Vice-Principal office 200

Faculty Room 1800

Administrative office 1000

Common room
Male 1000
Female
3

Toilets for Gents


1000
Toilets for Ladies
Fire extinguisher

Play ground Spacious


25 and 50 seater
Transport Facilities
bus as per
Garage
student strength
B. Hostel Block :- 17500

Number of Hostel females

Hostel Rooms (Single and double rooms) 9000(50 sq. ft.


for each
Student)
Toilet /Bath 1 Latrine and 1
bathroom 600 X
3= 18000
Pantry 1 on each floor

Dining Hall 3000

Recreation Room 500

Store Room 500

Visitor Room 500

Reading Room 250

Wardens Room 450

Kitchen and Store 1500

Name and Signature of Inspection


Signature of Principal with designation rubber stamp (1)____________________

(2)________________________
4

CLINICAL FACILITIES Name of Parent Hospital - _________________________

Type of Hospital: -__________________________ No. of San. Bed:- _____________

Sr. Name and Add. of Hospital No of No of No. of Nsg No of Annual


No. Parent / Affiliated beds Nsg. staff programme OPD deliveries
affiliated patients

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Name and Signature of Inspection


Signature of Principal with
designation rubber stamp (1)______________________________

(2)_____________________________
5

Affiliated Bed Occupancy of Affiliated Hospitals

Medicine Surgery Orthopaedic Pead. Ob/gyn EYE/ENT Oncology Iccu Psychiatric Emergency
* Name of Hospital

1 Beds

Occupancy

2 Beds

Occupancy

3 Beds

Occupancy

4 Beds

Occupancy

5 Beds

Occupancy

6 Beds

Occupancy

Name and Signature of Inspection


Signature of Principal with designation rubber stamp

(1) _________________ (2) ______________________

* Please note affiliated Hospital should not be more than 3 hospitals as per INC norms.
6

F COMMUNITY HEALTH FACILITES

I RURAL FIELD

Name of CHC/PHC/SC

(i) Adopted Affiliated Dist. From the Nsg.


Institute

(ii) Administrator by 1. State Government Y/N

2. Municipal Corporation

3. Private

II. URBAN FIELD

a. Name of the MCH & F.W. Center

(1) Adopted (2) Affiliated

b. Distance from MCH and F. W.


Centre
Distance from the Institute

(iii) Administrator by 1. State Government Y/N

2. Municipal Corporation

3. Private

c. Supervision of Students 1. Field Staff Only

2. College Teaching Faculty

3. Both

Name and Signature of Inspection

Signature of Principal with (1) ___________________________


designation rubber stamp

(2) ___________________________
7

TEACHERS RECORDS: -

Teachers Record Yes No Remarks


A. CLASS COORDINATORS RECORD
Internal assessment Records
Ward Procedure evaluation format
Case Study evaluation format
Case presentation evaluation format
Family care plan evaluation format
Community procedure evaluation format
B. ADMINISTRATIVE RECORDS
Students Admission Records
Cumulative record
Students Enrolment
Hospital affiliation letter from competent authority
Rural & Urban Experience affiliation letter from
competent authority
Plan for Staff Development Programme
Students Health Record
Year Wise Students Result
Record of Counselling Guidance
Students Leave Record
Teachers Attendance Record
Clinical Experience Correspondence
Plan for Staff Development Programme
Any Other

Signature of Principal with designation rubber stamp Name and Signature of Inspectors

(1)________________________

(2)________________________
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IMPLEMENTATION OF SYLLABUS

Implementation of Syllabus Yes No Remarks

Clinical Experience as per Syllabus

Theory Class as per syllabus

A Students Records :

Procedure Book

Midwifery Case Book

Nursing Care Plan

Family Care plan

Case Presentation

Case Studies

Daily Diary

Field Visit Report

Master File

Drug Book

Signature of Principal with designation Name and Signature of Inspectors


rubber stamp (1)_______________________ (2)________________________
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HOSTEL STAFF :-

Sr. No. No. in Vacant


Designation Remarks
no. Sanctioned Position since when
1. Warden Female (for
03
150 students)

2.
House Keeper 01

3. Cooks (for 20 students


01
each shift)

4.
Peon/Ayah 02

5.
Sweeper 02

6.
Gardner 02

7.
Chowkidar 03

Signature of Inspectors
Signature of Principal with designation
(1)__________________________
rubber stamp

(2)___________________________
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TEACHING STAFF INFORMATION: -


Total No. Yes No Remarks

1. Total No. of Teachers

2. Principal

3. Vice Principal

4. Appointment letter( of each)

5. Previous Relieving order

6. Registration with parent Council

7. Registration with Maharashtra


Nursing Council

8. Renewal Done

9. Smart card

10. Verified 16th No form and professional

Tax payment / Bank Statement

11. Teacher Student ratio 1:10 maintained

Signature of Principal with designation rubber Signature of Inspectors


stamp

(1)___________________________

(2)___________________________
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* Teaching Faculty Profile (Full-Time) of all the nursing programmes offered by this institution
(ANM, GNM, B.Sc., P.B. B.Sc., M. Sc. and any other) All nursing teachers of all the nursing
programmes details to be given irrespective of the program being inspected. (Attach extra sheet
as needed )

Sr Designation Name Reg.no Mobile Email- Experience Subject Subject Subject Remarks
no no. id hrs hrs taken
Clinical Teaching Taught allotted

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.
12

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

Name and Signature of the Inspectors


Signature of Principal with designation
rubber stamp 1)____________________________

2) ___________________________
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MNC AFFILIATION RECORDS: -

Sr.
MNC Affiliation records Yes No Remark
No.

1.
Inspection fees paid

2.
Bed affiliation Fees paid

3.
INC validity Fees paid

4.
Examination Fees paid

5.
Compliance of last
inspection submitted

6.
Obtained INC Validity

7.
Obtained University
Affiliation

8.
Any court matter

Name and Signature of the Inspectors

Signature of Principal with designation rubber


1)____________________________
stamp
2) ____________________________
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CHECK LIST
1. I have received the inspection Performa & have filled the same Yes No

2. Whether the Inspection report is completely filled after verification. Yes No

3. MNC Consent /affiliation letter (relevant year) verified and annexed. Yes No

4. University Consent /affiliation permission letter verified & Yes No


annexed

5. Land deed document verified & annexed. Yes No

6. Teaching Faculty Original Certificate, photos (self- Yes No


attested)Verified & annexed

7. Smart card obtaining Yes No

8. Documents with Respect to Parent hospital verified & Yes No


annexed

9. Affiliated Hospital Permission letter verified from Hospital & Yes No


annexed

10. Relieving order of teachers verified & annexed Yes No


11. Permission letter of CHC/PHC verified & annexed. Yes No

12. Transportation (Registration Certificate)verified & annexed Yes No

Signature of Principal with designation rubber Name and Signature of the Inspectors

stamp
1)___________________________

2) ___________________________
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RECOMMENDATIONS
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Name and Signature of the Inspectors

1)__________________________

2) __________________________