RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

JABEZ PAUL SAMUEL.N 1ST Year M.Sc. Nursing Medical Surgical Nursing Year 2012-2013

BRITE COLLEGE OF NURSING BENGALURU-91

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU, KARNATAKA. ANNEXURE-I

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1.

NAME OF THE CANDIDATE & ADDRESS

Mr. JABEZ PAUL SAMUEL.N 1st YEAR M.Sc. NURSING , BRITE COLLEGE OF NURSING , #69, BWSSB COLONY, CHIKKAGOLLARAHATTI, MAGADI MAIN ROAD, VISHWANEEDAM POST, BENGALURU 500 091.

2.

NAME OF THE INSTITUTION

BRITE COLLEGE OF NURSING , #69, BWSSB COLONY, CHIKKAGOLLARAHATTI, MAGADI MAIN ROAD, VISHWANEEDAM POST, BENGALURU 500 091.

3.

COURSE OF STUDY & SUBJECT

I YEAR M.Sc. NURSING , MEDICAL SURGICAL NURSING 30/06/2012 A STUDY TO ASSESS THE KNOWLEDGE REGARDING SELFCARE ABILITIES AMONG CEREBROVASCULAR ACCIDENT PATIENTS ADMITTED IN NEUROLOGICAL WARDS IN A VIEW TO DEVELOP INFORMATION GUIDE SHEET IN SELECTED HOSPITALS, BENGALURU.

4. 5.

DATE OF ADMISSION TITLE OF THE TOPIC

6. BRIEF RESUME OF INTENDED WORK INTRODUCTION

Strength does not come from physical capacity. It comes from an indomitable will. --Mahatma Gandhi Health is the level of functional or metabolic efficiency of a living being. In humans, it is the general condition of a person's mind and body, usually meaning to be free from illness, injury or pain1. Personal health depends partially on the active, passive, and assisted cues people observe and adopt about their own health. These include personal actions for preventing or minimizing the effects of a disease, usually a chronic condition, through integrative care. They also include personal hygiene practices to prevent infection and illness, such as bathing and washing hands with soap, brushing and flossing teeth, storing, preparing and handling food safely, and many others. The information gleaned from personal observations of daily living - such as about sleep patterns, exercise behavior, nutritional intake, and environmental features - may be used to inform personal decisions and actions1. Sorrow touches us all, but we can learn how to call upon the blessings of grace and loving kindness in our life and the lifes of our loved ones, yes, there is something we can do. Well open our heart and spirit to the possibilities that dwell within us, even at the worst times2. Personal health also depends partially on the social structure of a person's life. The maintenance of strong social

relationships, volunteering, and other social activities have been linked to positive mental health and even increased longevity1. More than 400 years before Christ, Hippocrates first described a clinical syndrome, which is labeled as apoplexy. In Greek it means, Stuck with violence or paralysis. The synonyms used for the stroke are cerebrovascular accident, apoplexy and hemiplegia2. Cerebrovascular disorder is an umbrella term that refers to any functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted. Stroke is the primary cerebrovascular disorder in the United states and in the world. Although preventive efforts have brought about
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a steady decline in incidence over the last several years, stroke is still the third leading cause of death2. There is no universally accepted definition of 'selfcare' in the wider healthcare field. Indeed, the terms 'self-care', 'self-management' or even 'self-help' tend to be used interchangeably. A couple of decades ago, the term 'self-help' was adopted to describe the mutual support and aid provided by self-help groups, typically in relation to a specific diagnosis such as pain, depression, arthritis. Over time, many self-help or voluntary organizations have responded to the needs of their members by providing more structured support in the form of workshops, seminars and interventions. Indeed, voluntary organizations have played a key role in promoting the development of selfcare / self-management support3. The World Health Organization defines selfcare as "the ability of individuals, families and communities to promote health, prevent disease, and maintain health and to cope with illness and disability with or without the support of a health-care provider". It is clear from the definitions that selfcare can encompass a wide-ranging spectrum of activities that can include simple acts such as brushing one's teeth regularly to prevent dental decay, selfcare has often been used in relation to behaviors such as a specific exercise regime, managing one's diet, or personal care (e.g. dressing oneself). It is worth noting that most people with disability spend most of their time managing at home on their own with relatively small amounts of contact time with rehabilitation professionals. Selfcare activities are dependent on an individual's needs at a given point in time and may vary over time and with the disease course. However, it is true to say that most conditions have specific selfcare activities. For a person with stroke the main focus of attention is likely to be on managing pain, inflammation, stiffness and fatigue. Selfcare may comprise use of appropriate medication to help control inflammation and pain thus allowing the individual to perform appropriate exercises that will help stiffness and mobility. Broader definitions of selfcare include not only management of symptoms and treatment but also management of psychosocial consequences and lifestyle changes. There is an increasing range of interventions being developed to enhance self-care using cognitive, behavioral, or cognitive-behavioural frameworks. Hence, learning

and performing selfcare activities designed to promote well-being and enhance quality of life are vital3. The area of selfcare encompasses all of the tasks an individual does throughout the day to look after his or herself. It includes activities such as personal care, functional mobility, and community management. Personal care includes such tasks as feeding oneself, bathing, personal hygiene, dressing, and toileting. Activities involved in community management may include driving, taking public transportation, grocery shopping, completing community errands, and managing one's finances4. Cerebrovascular accident is the primary neurological problem in the world and ranks third in the cause of death. There are t w o million people surviving strokes and needs assistance with activities of daily living2. Usually the quality and quantity of information received by stroke patients is inadequate or some time health personnel fail to impart the information or stroke patients may not assimilate the information properly. Knowledge of self-care activities helps cerebrovascular accident patients to come out from their dependency to a level of achievement and adjustment. Health &happiness depends on positive thinking and faith.

6.1NEED FOR THE STUDY

According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, five million die and another five million are permanently disabled. High blood pressure contributes to more than 12.7 million strokes worldwide. Europe averages approximately 650,000 stroke deaths each year .In developed countries, the incidence of stroke is declining, largely due to efforts to lower blood pressure and reduce smoking. However, the overall rate of stroke remains high due to the aging of the population5. Several population-based surveys on stroke were conducted from different parts of India. During the last decade, the age-adjusted prevalence rate of stroke was between 250-350/100,000. Recent studies showed that the age-adjusted annual incidence rate was 105/100,000 in the urban community of Kolkata and 262/100,000 in a rural community of Bengal. The ratio of cerebral infarct to hemorrhage was 2.21.
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Hypertension was the most important risk factor. Stroke represented 1.2% of total deaths in India6. A longitudinal study on predicting mortality in stroke among patients admitted to 12-bedded medical ICU at Mahatma Gandhi Institute of Medical Sciences, Sevagram over a period of 12 months. APACHE III scoring system was used to calculate the score and it was correlated with immediate in-hospital outcome of this patients. The sensitivity and specificity of this score was calculated at a cutoff point of 40. The results revealed that seventy-four patients were admitted with diagnosis of stroke in one year.30 patients had intra cerebral hemorrhage (40.5percent) and 44 had infarction (59.5percent).17 patients out of 30 in the hemorrhagic group (56.6percent) and 10 out of 44 (22.7percent) in infarctions group had died. The overall mortality observed was 34percent in all the patients. The sensitivity and specificity of APACHE III scoring systeming predicting mortality was 94.12 percent and 53.85percent respectively in patients with hemorrhage and 90percentand 73.53percent respectively for ischemic stroke when a cutoff point of 40 was taken. Likelihood of mortality had increased as the score increased. The study concluded that predicting outcome in stroke patients is difficult due to variability in etiology and pathophysiology APACHE III scoring system was found to be sensitive and reasonably specific in predicting short term, inhospital outcome of critically ill patients having Cerebrovascular accident7. Cerebrovascular accident is the primary neurological problem in the world. Although preventive efforts have brought a steady decline in its incidence in last several years, stroke is the third ranking cause of death, with an overall mortality rate of 18percent to 37percent. There are approximately two million people surviving strokes that need assistance with activities of daily living2. A longitudinal study on follow up of stroke patients was conducted in which 231 stroke patients were selected. After 6 months of discharge when sample were reviewed it was revealed that 34 patients (14.7percent) had died and 115 patients (58percent) were independent and living in community. 42percent of sample were dependent and majority of them were in institutional care.29 patients (36percent) were residing in community of whom a substantial number were not receiving physiotherapy, occupational therapy or day care. The study also revealed that patients who were dependent in nursing homes were less likely to have received
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physiotherapy (48:70) or occupational therapy (28:60) compared to disabled patients in hospitals based extended nursing care. The study concluded that most of the dependent survivors of cerebrovascular accident had ongoing unmet

rehabilitation needs8. A longitudinal, descriptive and co relational design was adopted on self-care self efficacy, quality of life and depression after stroke. The setting of study was inpatient rehabilitation facility at one month after stroke and home at six months after stroke among sample of sixty-three stroke survivors. Main outcome measured four instruments used by people to promote health, quality of life, index stroke version, center for epidemiological studies depression scale and functional independence measure. The results of the study showed self-care, self-efficacy increased after stroke and was strongly correlated with quality of life and depression at one and six months after stroke. Functional independence and quality of life increased, while depression decreased. Functional independence was correlated with quality of life at six months after stroke and the study concluded self care self efficacy, is strongly related to quality of life and depression.9 Rehabilitation goals of self-care enable clients to move away from a period of dependency to a level of achievement and adjustment. Client may be able to groom himself, including cleaning his teeth, washing his face, combing his hair, dress himself and applying his make up on his own. The above studies created an insight in investigators mind that there is a need for the study to assess knowledge on self-care abilities among Cerebrovascular accident patients, which will help the investigator in preparation of an informative guide sheet in care of Cerebrovascular accident patients.

6.2REVIEW OF LITRERATURE
According to Polit and Hungler literature reviews are critical summaries of what is known about a particular topic, with a background for understanding what has been already learned on a topic and facilitates accumulation of knowledge and illuminates what the significance of the new study is. It integrates a body of research problem in context (or) to identify gaps and weakness in prior studies so as
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to justify a new investigation in order to point the why or further knowledge and development10. The review of literature of the study is divided into two headings: Literature related to occurrence of Cerebrovascular accident. Literature related to knowledge of Cerebrovascular accident patients on self-care abilities.

LITERATURE RELATED TO OCCURRENCE OF CEREBROVASCULAR ACCIDENT. A study conducted on etiological factors of stroke among the patients admitted in department of neurology in Asia during 1988 to 1997 revealed that out of 940 patients admitted 127 (13.5percent) had stroke at younger age. Ischemic stroke had accounted for 85.8percent & 14.2percent had spontaneous intra cerebral hemorrhage. In cases of cerebral infarction 29.4 percent had cardio embolic stroke, followed by atherosclerotic occlusive disease in 22percent and non-atherosclerotic vascular disease in 15.6percent of patients. Study concluded that the major risk factors for stroke in young patients were hypertension, hypercholesterolemia, hyper triglyceridemia and smoking.11 A community-based tri-racialcross-sectional survey on Prevalence rates of stroke were studied among Singaporeans aged 50 and above of Chinese, Malay, and Indian origin. A disproportionate stratified random sampling by race was used and data collected by face-to-face interviews using WHO screening protocol for neurological diseases. The study involved 14 906 participants: 6734 men, 8172 women, age range 52 to 106 years, Chinese:Malay:Indian ratio 3:1:1.Prevalence rates a rose with age and were higher among men compared with women, 4.53% versus 2.91%. Age and gender- standardized rates among Chinese, Malays, and Indians were 3.76%, 3.32% and 3.62%.12 The Stroke Association states a newsletter published by BBC 2004, each year. 1,30,000 people in UK suffer from stroke. It also highlighted that men were at more risk than women. Other risk groups included smokers, people who were

obese, high BP, heart disease, diabetes, people with a genetic link first-degree

relative who had stroke at an early age.13 A population based cluster survey conducted on stroke disorders among the urban population of Calcutta. The population surveyed was 50,291. The results of the study highlighted that prevalence of stroke was 147/ 1,00,000 and annual incidence for 19981999 was 36/1,00,000. Women had outnumbered men in stroke in all age groups except in 5069 year age group. The study found hypertension as most significant risk factor for stroke.14 A cohort study w a s c o n d u c t e d to identify whether individual socioeconomic status and community socio-economic status a t N e w z e a l a n d predicts the onset of stroke both independently and after controlling for individual risk factors such as smoking, obesity, hypertension. The results suggest that individual income a significant predictor of smoking and obesity are significant predictors of onset of stroke both independently and after controlling for behavioural and medical risk factors, and that community socio-economic status is a significant predictor of stroke both independently and after controlling for behavioural and medical risk factors and that community socio-economic status is a significant predictor of heart disease, heavy drinking, diabetes, smoking and obesity.15 A study was conducted to measure knowledge about the symptoms, prevalence and natural history of stroke; the level of concern about having a stroke; understanding of the possibilities for preventing stroke, and the relationship between age, sex, country of origin, educational level, income, self-reported risk factors, and the above factors in Australia. This community-based study demonstrates aspects of public knowledge and perception about stroke. Of 822 respondents, 694 (85.5%) were able to name at least one established stroke symptom. Respondents, in general, overestimated both stroke prevalence in Australia and the chance of full recovery after the stroke. Respondents generally considered the possibility of their having a stroke during their life as being not a matter of serious concern. In a multiple logistic regression model, only one group those with a higher level education had better knowledge of established stroke symptoms.16

LITERATURE RELATED TO KNOWLEDGE OF CEREBROVASCULAR ACCIDENT PATIENTS ON SELF- CARE ABILITIES A study was conducted on families dealing with stroke desire information about self- care needs at Australia. The study states as hospital lengths of stay have decreased, opportunities to educate stroke patients and families regarding self-care decreased. Twenty-four people responded to a survey that listed 48 self-care needs within Orems universal self-care requisites. The top five self-care needs about

which information was desired were preventing falls, maintaining adequate nutrition, staying active, managing stress and dealing with emotional mood changes.17 A study was conducted in on patients characteristics associated with perceptions of stroke education i n S out h Korea. It involved fifty consecutive patients with acute stroke and 88 medical professionals (31 doctors and 57 nurses) working in the Departments of Neurology. They were administered a structured questionnaire regarding various aspect of patient education concerning stroke. Results showed the average ranking of total items for stroke education was higher in nurses than in doctors or patients (P < 0.01 for each). Patients gave higher rankings than doctors for 'possibility to cure with drug treatment' (P < 0.01), 'stress management' (P < 0.01), and most items concerning 'general medical knowledge' and 'post-stroke diet management,' whereas doctors gave higher rankings than patients for most items concerning risk factor management and treatment with surgery. Items concerning 'post- stroke diet management' were ranked lower by male patients than female patients (P < 0.005), and were ranked lower by doctors than by patients or nurses (P < 0.001). Younger patients gave higher rankings than older patients for items concerning medical knowledge regarding stroke, 'exercise,' and 'post-stroke sexual activities.18 A study conducted about the autonomy of stroke patients in rehabilitation wards in which twenty seven health care providers from three nursing homes were interviewed. The core category 'changing autonomy' was developed, which identifies the process of stroke patients regaining their autonomy (dimensions: selfdetermination, independence and self-care), and the factors affecting this process (conditions and strategies of patients; strategies of care providers and families; and
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the nursing home). Team work on increasing patient autonomy is recommended, which can be stimulated by multidisciplinary guidelines and education, and by coordination of the process of changing autonomy.19 A study was conducted at rehabilitation centers in northern Ohio and southern Michigan to examine the emotional support, physical help, and health of caregivers of stroke survivors, 2008. This study was guided by Orems (2001) self-care deficit nursing theory, which is based on the concept of self-care, where individuals perform specific learned activities to maintain health and well-being. The results of this study highlight the importance o dependent care agents, establishing an adequate self-care system that provides emotional support and physical help20.

STATEMENT OF PROBLEM A STUDY TO ASSESS THE KNOWLEDGE REGARDING SELFCARE ABILITIES AMONG CEREBROVASCULAR ACCIDENT PATIENTS

ADMITTED IN NEUROLOGICAL WARDS IN A VIEW TO DEVELOP INFORMATION GUIDE SHEET IN SELECTED HOSPITALS, BENGALURU.

6.3 OBJECTIVES

1) To

assess

the

knowledge

regarding

selfcare

abilities

among

Cerebrovascular accident patients. 2) To prepare an information guide sheet regarding selfcare abilities among Cerebrovascular accident patients. 3) To find association between the knowledge of Cerebrovascular accident patients regarding self-care abilities with selected demographic variables.

6.3.1 VARIABLES

1. Independent variable: Self-care abilities. 2. Dependent variable: Knowledge regarding self-care abilities.

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3. Demographic variables: Age, gender, religion, education, occupation, family income and source of information. 6.4 OPERATIONAL DEFINITIONS

a) Selfcare abilities: It refers to the ability of the client to meet the activities of daily living such as bathing, walking, grooming, dressing, eating and attending toilet without help.

b) CerebroVascular Accident: It refers to the rapid loss of brain function due to disturbance in the blood supply to the brain.

c) Patients: It refers to the individuals who are diagnosed with Cerebrovascular accident admitted in neurological wards. d) Information guide sheet: A printed guide sheet which contains information on self care abilities of Cerebrovascular Accident which will be in self directed nature.

6.5 HYPOTHESIS

H1 There will be significant relationship between the knowledge score on self-care abilities among Cerebrovascular accident patients with their selected demographic variable.

6.6 ASSUMPTIONS:

Cerebrovascular accident patients may develop some selfcare abilities for better quality of life. Cerebrovascular accident patients may gain knowledge through information guide sheet about selfcare abilities.

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6.7 LIMITATIONS:

1. The study is limited to age group 40-70years. 2. The study is limited to those who are willing to participate in the study 3. The study is limited to those who dont have cognitive impairment.

7. MATERIALS AND METHODS

7.1 Sources of Data: Cerebrovascular accident patients in neurological wards of selected hospital, Bengaluru.

7.1.1 Research Approach: Descriptive research approach.

7.1.2 Research design:

Qualitative study design.

7.1.3 Setting:

Selected neurological hospitals at Bengaluru.

7.1.4 Sample:

Cerebrovascular accident patients.

7.1.5 Population:

Patients in neurological wards at selected hospitals, Bengaluru.

7.1.6 Sample size:

60 samples.

7.1.7 Inclusion criteria: Adults who are: Age group between 40-70 years irrespective of gender. Available during the time of data collection. Can communicate in Kannada or English.

7.1.6 Exclusion criteria: Adults those who are not willing to attend the study. Adults those who have cognitive impairment.
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7.2 Method of collection of data:

7.2.1 Sampling technique: Purposive sampling.

7.2.2 Duration of study:

The study will be conducted in duration of 30 days.

7.2.3Tool of research:

Structured knowledge questionnaire.

Structured knowledge questionnaire will be constructed in two parts. Part I -Demographic data. Part II- Knowledge based structured questionnaire regarding selfcare abilities among cerebrovascular accident patients.

7.2.3 Collection of data

1. The investigator himself collects the data from the cerebrovascular accident patients admitted in neurological ward. 2. Structured knowledge questionnaire will be used to access the knowledge regarding selfcare abilities.

7.2.4 Method of data analysis and data presentation

a) Descriptive statistics 1. Frequency and percentage distribution will be used to describe the demographic variable of cerebrovascular accident patients. 2. Mean, median, mean percentage, range standard deviation will be used to describe the knowledge regarding self care abilities. b) Inferential statistics 1. Chi-square test will be used to find the association between knowledge of cerebrovascular patients regarding selfcare abilities with selected demographic variables

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c) The analyzed data will be presented in the form of tables, diagrams and graphs based on findings.

7.3

Does the study require any investigation to be conducted on patients or other human or animals? If so please describe briefly? Yes, the study is done on cerebrovascular accident patients.

7.4 Has ethical clearance has been obtained from your institution?

Yes, Consent will be obtained from concerned authority and subjects.

Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be maintained with honesty and impartiality.

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8. LIST OF REFERENCES

1. Health. Article about human condition [serial online] [cited 2012 Dec 3];
Available from: URl:http://en.wikipedia.org/wiki/Health

2. Suzanne CS, Brenda GB, Brunner and Suddarths. Text book of Medical
Surgical Nursing. 8th ed. Lippincott company, Philadelphia .2004.p.1888-90. 3. Julie Barlow. Selfcare. International Encyclopedia of Rehabilitation. [cited 2012 Dec 3]; Available from: Url:http://cirrie.buffalo.edu/encyclopedia/en/article/334/ 4. Occupational Therapy .Self-care Aging, Client, and Bathing. JRank Articles [online][cited 2012 Dec 3]; Available from: Url:http://medicine.jrank.org/pages/1259/OccupationalTherapy/SelfCare.html #ixzz2G6gGFXaW 5. Stroke statistics. The internet stroke centre. [Online] [cited 2012 Dec 4]; Available from: Url:http://www.strokecenter.org/patients/about-stroke/stroke-statistics 6. Stroke survey. Neurological journal of south east asia. [Online] 2006[cited 2012 Dec 4]; Available from: Url:http://www.neurologyasia.org/articles/20061 7. Bhalla, Gupta. Predicting mortality in stroke. Neuro India. 2004; 50: p.279 81. 8. No one et al, Stroke patients after hospital discharge I r Med j. 2004. 94 (5): p.151 2. 9. Smith, Johnson, Allen. Self-care, self-efficacy, quality of lifes depression after stroke. Arch phys Med Rehab.2003; 81 (4) : 460 4. 10. Polit D E, Bernadette P. Hungler. Nursing research and principles and methods. 5th ed. Philadelphia: Lippincot publication.; 2005. 11. Mehndiratta M M. stroke among young adults. Journal of medical science Monitoring.2004 ;10 (9): p. 535 541. 12. Venketasubramanian N, Tan LC, Sahadevan S, Chin JJ, Krishnamoorthy ES, Hong CY, et.Al. Prevalence of stroke among Chinese, Malay, and Indian Singaporeans: a community-based tri-racial cross-sectional survey. Journal of Stroke. 2005 March; 36(3): 551-6.
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13. Frih Ayed M, Chelbel S, Ben Hamda K, Maatoug F. Ischemic stroke in young adults. Tunis Med.2004.Jun;82 (6):506-11. 14. BanerjeeTK, MukherjeeCS, SarkhelA. Stroke in urban population. Journal of association of physicans.2003May; 46 (4): 351 4. 15. Brown P, Guy M, Broad J. Individual socio-economic status, community socio- economic status and stroke in New Zealand: a case control study. Soc Sci Med. 2005 Sep; 61(6): 1174-88. 16. Sung Sug Yoon, Richard F Heller, Christopher Levi, John Wiggers. Knowledge and perception about stroke among an Australian urban population. BMC Public health.[online]7 July 2004 [cited 2012 Dec 5]; Available from: Url:http://www.biomedcentral.com/1471-2458/1/14 17. Pierce, Gordon, Steiner. Families dealing with stroke desire information about Selfcare needs 2004 .29 (1): 14 7 18. Choi-Kwon S, Lee SK, Park HA, Kwon SU, Ahn JS, Kim JS. What stroke patients want to know and what medical professionals think they should know about stroke. Journal on Patient Education and Counseling. 2005 Jan;56(1): 85-92. 19. Proot IM, Abu-Saad HH, Van Oorsouw GG, Stevens JJ.Autonomy in stroke rehabilitation: the perceptions of care providers in nursing homes. Journal of Nursing Ethics. 2002 Jan; 9(1): 36-50 20. Victoria Steiner, Linda Pierce, Sean Drahuschak, Erin Nofziger, Debra Buchman. Emotional Support, Physical Help, and Health of Caregivers of Stroke Survivors. NIH public ascess [online][cited 2008 Feb 4]; Available from: Url:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442227/#R32

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Signature of Candidate

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Remarks of the Guide

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11.1 Name & Designation Of Guide

Mrs. VIJI.C. Associate Professor, Brite college of nursing Chikkagollarahatti, bengaluru -560091

11.2

Signature

11.3

Co-Guide

Mrs. Rajashree.S.S. Lecturer, Brite college of nursing Chikkagollarahatti, bengaluru -560091

11.4 11.5

Signature Head of the Department Mrs. VIJI.C. Associate Professor, Brite college of nursing Chikkagollarahatti, bengaluru -560091

11.6 12 12.1

Signature Remarks of the Principal

12.2

Name and Signature

Prof. H.H.DASEGOWDA

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