Amendment status not verified — confirm the current text below against the official source.
Trained persons for Keratoplasty and Corneal Transplantation with their names and qualifications: 2 (one Corneal Transplant surgeon should be on the pay ro ll of the Institute) C Equipment : Slit lamp, Clinical Specular, Keratoplasty or intraocular instruments D OT facilities E Safe Storage facility F Records Registration and follow up G Any other information The above said information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorised personnel. A Bank draft/cheque of Rs. 10000- for new registration and Rs 5000/ for renewal of registration drawn in favour of ______ is enclosed. Head of the Institute (Name and designation) FORM 16 CERTIFICATE OF REGISTRATION FOR PERFORMING ORGAN/TISSUE TRANSPLANTATION/RETRIEVAL AND/OR TISSUE BANKING (S e e ru le 2 4 (2 )) This is to certify th at.......................................Hospital/Tissue Bank located at...................................... has been inspected and certificate of registration is granted for performing the organ/tissue retrieval/transplantation/banking of the following organ(s)/tissue(s) (mention the names) under the Transplantation of Human Organs Act, 1994 (42 of 1994):- 1..................................................................... 2..................................................................... 3 ................................................................. 4 ................................................................. This certificate of registration is valid for a period of five years from the date of issue. This permission is being given with the current facilities and staff shown in the present application form. Any reduction in the staff and/or facility must be brought to the notice of the undersigned. Place............................................. Signature of Appropriate Authority.............................. Seal:.................................................... Date FORM 17 Certificate of Renewal of Registration (To be given by the appropriated authority on the letter head) [See rule 25(2)] This is with reference to the application dated.............................. from ............................ (Name of the hospital/tissue bank) for renewal of certificate of registration for performing organ(s)/tissue(s) retrieval/transplantation/banking under the Transplantation of Human Organs Act, 1994 (42 of 1994). After having considered the facilities and standards of the above-said hospital/tissue bank, the Appropriate Authority hereby renews the certificate of registration of the said hospital/tissue bank for a period of five years. [HTX I I - [ F M 3 ( i ) ] HTTT d T TTtdT : V lT / T T 69 This renewal is being given with the current facilities and staff shown in the present application form. Any reduction in the staff and/or facility must be brought to the notice of the undersigned. Place............................................. Signature of Appropriate Authority.............................. Date.......................................... Seal............................................................................................. FORM 18 Certificate b y th e A u th o r is a tio n C o m m itte e o f H o s p ita l ( I f H o s p ita l A u th o r is a tio n c o m m itte e is n o t a v a ila b le th e n th e A u th o r is a tio n C o m m itte e o f th e d is tr ic t/S ta te ) w h e r e th e tr a n s p la n ta tio n h a s to ta k e p la c e (T o b e is s u e d o n th e le tte r h e a d ) [See rules 16 and 231 T h is is to c e rtify th a t a s p e r a p p lic a tio n in fo r m - 1 0 f o r tr a n s p la n ta tio n o f _____________________(N a m e o f O r g a n /tis s u e ) fr o m liv in g d o n o r, o th e r th a n n e a r r e la tiv e / sw a p d o n a tio n c a s e s / a ll fo r e ig n e r u n d e r th e T r a n s p la n ta tio n o f H u m a n O r g a n s A c t,1 9 9 4 (42 of 1994) s u b m itte d o n ..................................b y th e d o n o r a n d re c ip ie n t, w h o s e d e ta ils a n d p h o to g r a p h s a re g iv e n b e lo w , a lo n g w ith th e ir id e n tific a tio n s a n d v e r ific a tio n d o c u m e n ts , th e c a s e w a s c o n s id e r e d a fte r th e p e r s o n a l in te r v ie w o f d o n o r a n d r e c ip ie n t ( i f m e d ic a lly f i t to b e in te r v ie w e d ) a n d th e ir r e la tiv e s a s a p p lic a b le b y th e A u th o r is a tio n C o m m itte e in th e m e e tin g h e ld o n ...d a te d ................................................. D e ta ils o f R e c ip ie n t D e ta ils o f D o n o r N a m e.............................................. N a m e :................................................. A g e ................................................. A g e ..................................................... S e x ................................................ S e x ..................................................... F a th e r / H u s b a n d N a m e .............. F a th e r / H u s b a n d n a m e.................... A d d d r e s s : A d d r e s s : H o s p ita l R e g . N o ........................... H o s p ita l R e g . N o. R e la tio n o f d o n o r w ith R e c ip ie n t .................................................................................. R e c ip ie n t D o n o r (P h o to o f r e c ip ie n t a n d d o n o r m u s t b e s ig n e d a n d s ta m p e d a c r o s s th e p h o to a fte r a ffix in g ) P e r m is s io n is g r a n te d , a s to th e b e s t o f k n o w le d g e o f th e m e m b e r s o f th e c o m m itte e , d o n a tio n is o u t o f lo v e a n d a ffe c tio n a n d th e r e is n o fin a n c ia l tr a n s a c tio n b e tw e e n r e c ip ie n t a n d d o n o r a n d th e r e is n o p r e s s u r e o n / c o e r c io n o f th e d o n o r. P e r m is s io n is w ith h e ld p e n d in g s u b m is s io n o f th e fo llo w in g d o c u m e n ts .............................................. P e r m is s io n is n o t g r a n te d f o r th e fo llo w in g re a s o n s (M e m b e r) N a m e a n d D e s ig n a tio n (M e m b e r) H e a lth S e c r e ta r y O r N o m in e e D a te a n d p la c e ............... (M e m b e r ) (M e m b e r ) (M e m b e r) N a m e a n d D e s ig n a tio n N a m e a n d D e s ig n a tio n N a m e a n d D e s ig n a tio n (M e m b e r ) ( S ig n o f C h a ir m a n w ith sta m p ) D H S o r N o m in e e N a m e a n d D e s ig n a tio n N a m e a n d D e s ig n a tio n * In c a se o f S W A P tr a n sp la n ts, d e ta ils a r e to b e a n n e x e d FORM 19 Certificate by competent authority [as defined at rule 2(c)] For Indian near relative, other than spouse, cases (In case of spousal donor, Form 6 w ill be applicable) [See rule 5(3)(c)] (Format for the decision of Competent Authority) This is to certify that as per application in Form-11 for transplantation o f_______________________(Name of Organ or Tissue) from living donor who is a near relative of the recipient under the Transplantation of Human Organs Act, 1994(42 of 1994), submitted on......................................by the donor and recipient, whose details and photographs are given below, along with their identifications and verifications documents, the case was considered after the personal 70 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] interview of donor and recipient (if medically fit to be interviewed) by the competent authority in the meeting held on Details of Recipient Name.................................. Age..................................... Sex..................................... Father or Husband Name Adddress: Details of Donor Name:................................ A ge................................... Sex................................... Father or Husband name Address: Hospital Reg. N o ............................... Hospital Reg. No Relation of donor with Recipient............................................................................... Recipient Donor (Photo of recipient and donor must be signed and stamped across the photo after affixing) Permission is granted, as to the best of knowledge of the members of the committee, donation is out of their being near relative and there is no financial transaction between recipient and donor and there is no pressure on / coercion of the donor. Permission is withheld pending submission of following documents....................................... Permission is not granted for the following reasons (Signature and stamp of competent authority) Date and place............................................... FORM 20 Verification certificate in r e s p e c t o f d o m ic ile s ta tu s o f r e c ip ie n t o r d o n o r [ T o b e is s u e d by tehsildar or any other authorised officer f o r th e p u r p o s e (r e q u ir e d o n ly f o r th e d o n o r - o th e r th a n n e a r re la tiv e o r r e c ip ie n t i f th e y d o n o t b e lo n g to th e s ta te w h e r e tr a n s p la n t h o s p ita l id e n tifie d f o r o p e r a tio n is lo c a te d )] [See rule 14] Part I (To be filled by applicant donor or recipient separately in triplicate) In reference to application for verification of domicile status for donation o f__________________________(Name of organ/Tissue) from living donor (other than near relative) or recipient under Transplantation of Human Organ Act, 1994 (42 of 1994), submitted on (date)......................................by the applicant donor or recipient, with following details and photograph , along with his or her identification and domicile status for verification Details of Applicant Recipient or Donor Name.................................................... Age....................................................... Sex...................................................... Father or Husband Nam e................ Address: Hospital Reg. No (Recent Photo of Applicant must be signed by him or her across the photo after affixing it) The detail of my donor or recipient are as under and I have enclosed his or her self-signed recent photograph : Name.................................................... [ HTX II-[F M 3(i) ] HTTT d T TTtdT : V lT / T T 71 Age..................................... Sex..................................... Father or Husband Name Address: Hospital Reg. N o ............................... Signature of Applicant Enclosure : Self signed copy of the donor or recipient for the applicant (to be enclosed ) Part II (To be filled by the certificate issuing authority): T h e a b o v e r e q u e s t h a s b e e n e x a m in e d a n d it is c e r tifie d th a t th e d o m ic ile s ta tu s o f th e a p p lic a n t d o n o r o r r e c ip ie n t m e n tio n e d a s a b o v e h a s b e e n v e r ifie d a s u n d e r: N a m e .............. S o n o r D a u g h te r o r W ife o f ............................. r e s id e n t o f v illa g e o r w a r d ...............,.................. ,T e h s il o r T a lu k a........................ D is tr ic t................... S ta te o r U T ...................... a n d fo u n d c o r r e c t o r in c o r r e c t D ate........................Place............................. Authorised Signatory Reference No Name and Designation Office Stamp