2/23/2019 Specialty Specific Application Form

SAMPLE FORM
For

DNB - Medical Oncology

This sample form is for reference only to provide OVERVIEW of ONLINE

APPLICATION FORM. Please DO NOT fill this form for submission of
application to NBE for seeking accreditation. This shall not be acceptable.

(For seeking Fresh/Renewal of Accreditation with National Board of Examinations in year 2019)

Bar-Coded DNB - Medical Oncology

Application Form

General Information of Applicant Department

Step:

GENERAL INFORMATION OF THE DEPARTMENT FOR WHICH ACCREDITATION IS BEING

1.
SOUGHT

Unique Onlline Application Registration

1.1.
ID

1.2. Nature of Application Fresh

Name of the Specialty DNB - Medical Oncology

Number of DNB - Medical Oncology

Seats applied for

(Specialties wherein NBE administers Post Diploma

DNB Programme also, equal number of DNB- Post 0
MBBS and DNB- Post Diploma candidate(s) will be
alloted. For example, if accreditation is granted for
1.3. 2 seats, 2 DNB Post MBBS Candidates and 2 DNB
Post Diploma Candidates shall be alloted.)

If yes:
Whether the hospital is running any
parallel academic programme of similar
Yes/No Programme
nature (in affiliation with other
Programme Name Duration
universities/organization) for 2-3 years
(in year)
(or more) duration

1.4. Name of Applicant Institution / Hospital XYZ Hospital

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1.5. Address of the Institution / Hospital New Delhi, Delhi-110075

Name of the Parent Company (as per

1.6. RoC/ Trust / Society / Charity) running XYZ Co. Pvt. Ltd.
the hospital / institute)

Head of the Department / Course Name Mobile Number Email ID

1.7.
Director

Transaction Details of Accreditation Processing Fees

Fee Receipt
1.8. Trn. No. Fee Amount Date Drawee Bank Beneficiary Bank Verification
Date

INR /- Print Fee Receipt

Acknowledgement

For any changes in the Name & Address of the hospital, please write to NBE through email at email ID
accr@natboard.edu.in . The request email for any changes in the Name & Address of the hospital should be received
only from the email ID of Single Point of Contact as mentioned in Online Accreditaiton Application Portal. Such
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request from any other email ID shall not be entertained.
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Infrastructure in the Department

Step:

2.1. BEDS IN THE APPLICANT DEPARTMENT

Total Operational Beds in the Applicant Department Number of General Beds * in the Applicant
Department
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* General Beds: General Beds are those 'earmarked' beds/cases whose patients shall be accessible at all times for supervised clinical work to DNB
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trainees. Data of patients admitted on such beds or such cases shall be acccessible to DNB trainees for research purposes subject to applicable ethical
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guidellines annd clearances from institutional Ethics Committee & institutional pollicies. As per NBE norms, at least 30% beds should be allocated.
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Patient Load
Step:

3. PATIENT LOAD IN THE SPECIALTY

3.1. IPD Admissions in the Applicant Department (Exclusively for MEDICAL ONCOLOGY)

Total Number of Patient admitted in the Total Number of General* Patient admitted
Year
department in the department

2018

2017
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3.2. OPD Registration by the Applicant Department (Exclusively for MEDICAL ONCOLOGY)

Total Number of Patients registered by the Total Number of General* Patient

Year
department registered by the department

2018

2017

3.3. Case Mix/Spectrum of Diagnosis Available in the Specialty:

Year Wise No. of Clinical Cases/ Surgical Procedures

Case Mix / Spectrum of Clinical/Surgical Diagnosis
2018 2017

Carcinoma Breast

Carcinoma Ovary

Carcinoma Endometrium

Carcinoma Cervix

Carcninoma Pancreas

Carcinoma Colon

Carcinoma Rectum

Carcinoma Anal Canal

Carcinoma Lung

Hodgkins Lymphoma

Non Hodgkins Lymphoma

Acute Lymphoid Leukemia

Acute Myeloid Leukemia

Carcinoma Head and Neck

Cholangiocarcinoma

Carcinoma GE Junction

Carcinoma Stomach

Sarcoma

Carcinoma Esophagus

Carcinoma Gall Bladder

Radiotherapy Case Load

Modalities/ Facilities

Three-dimensional Conformal Radiation

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Therapy (3D-CRT)

Stereotactic Radiosurgery (SRS)

Stereotactic Body Radiation Therapy (SBRT)

Intensity Modulated Radiation Therapy (IMRT)

VMAT (Volumetric Modulated ArcTherapy)

Image Guided Radiation Therapy (IGRT)

Brachytherapy

Any other Diagnosis / Procedures that are not listed above

SPECIAL CLINICS
3.4.
Name of special clinics (as relevant to the specialty) and the number of times the clinic is held in a week.

Total number of cases

Name of Clinics No. of times per week
seen last year

Chemotherapy Evaluation

LL Clinic

Breast Clinic

GE Clinic

H & N clinic

Gynae. Cancer Clinic

Ophthalmic tumour Clinic

BMT Clinic

Bone & Soft Tissue Clinic

Urology Clinic

Pediatric Surgery clinic

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Academic Facilities & Infrastructure

Step:

4. ACADEMIC FACILITIES & INFRASTRUCTURE

Number of Books available for DNB - Medical Oncology Programme in the Hospital/Institute
4.1. 0
Library

4.2. Details of Journals subscribed for DNB - Medical Oncology trainees

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Validity
Date of
Category Title of the Journal Version Publisher Details up to
Subscription
(Year)

4.3. Rotational Posting of Trainees

DNB - Medical Oncology trainees should be rotated / posted in different modalities / departments / areas / OTs such
that exposure as prescribed can be ensured.

Tentative schedule Name & Address of the

Supervising
Department / Area of Rotation (In Days OR institute / hospital where
Consultant Name
Month(s)) trainees are posted for rotation

Inpatient Posting 8 - 12 months

Out Patient Department (OPD)

16 months
Posting

Day Care and OPD Procedures

4 months
(Minor OT) Posting

BMT Unit Posting 2 months

Elective posting 6 weeks

Ancillary Posting:

Surgical oncology 3 weeks

Radiation oncology 3 weeks

Laboratory 4 weeks

Rotation to blood bank and

1 week each
Nuclear Medicine department

Radio diagnosis & Nuclear

2 weeks
Medicine
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Certified copy of MoU with other NBE accredited institute / hospital or medical college where DNB - Medical
Oncology trainees are posted for any of the above rotations, if the same is not feasible within the institute/hospital is
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required to be enclosed with hard copy of Specialty Specific Application which is to be submitted to NBE.
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Full Time Faculty/Staff

Step:

5.1. FULL TIME STAFF IN THE APPLICANT DEPARTMENT

(Please refer Information Bulletin for Accreditation for details of Minimum Faculty requirments)

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2/23/2019 Specialty Specific Application Form

Proposed Faculty in the Department:

The information shall be derived by the system from the declarations submitted for proposed faculty.

NBE
Whether Criteria
Faculty Post PG Number of
Name & Proposed fulfilled to Faculty Submission
Proposed Experience Research
Qualification as PG qualify as Declaration Status
As (in years) Activities
Teaher? a PG
Teacher

NO FACULTY HAS BEEN ADDED SO FAR

Research Activities of the Faculty in the applicant Department

5.2. (Research Activities may be Publications such as research papers, review articles, case reports, abstracts, papers/poster presented in conferences
etc.)

RESEARCH PUBLICATIONS

Nature of Research
Name of the Faculty Research Publications (Vancouver citation style)
Activities

PAPER/POSTER PRESENTATION
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Name of Date of Nature of
Title of the Presentation Name of Conference
Presenter Presentation Presentation
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Academic Sessions & Track Record

Step:

TRACK RECORD OF DNB - MEDICAL ONCOLOGY TRAINEES IN FINAL / EXIT EXAMINATIONS

CONDUCTED BY NBE:
6.1.
PLEASE PROVIDE THE DETAILS OF LAST 5 YEARS ONLY

Year in which Year for

Result
Training NBE last appeared Thesis
Name of the Acceptance
Status of Registration for Final /
Candidate (Applicable for
Candidate Number Exit
Examinations
DNB Programme Theory Practical
only)

SINCE GRANT OF FIRST ACCREDITATION TO THE APPLICANT DEPARTMENT:

a. How many DNB - MEDICAL ONCOLOGY Trainees have been registered in the
department?

b. How many DNB - MEDICAL ONCOLOGY Trainees have completed their training?

c. How many DNB - MEDICAL ONCOLOGY Trainees have qualified their Final / Exit
Exams?

6.2. Academic Sessions Conducted by the Department during year 2018

Academic Session for Date / Period

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Topic Presenter's Name

DNB/FNB Trainees (dd-mm-yyyy)
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2/23/2019 Specialty Specific Application Form

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Upload Documents
Step:

7. UPLOAD SUPPORTIVE DOCUMENTS

Link for access to Uploaded

Document/File uploaded
documents

Certified copy of MoU in case DNB - Medical Oncology trainees of applicant hospital are proposed
to be posted for externship at other NBE accredited institute / hospital or medical college in the
area/department which training is not feasible within the applicant institute/hospital. No Doument Uploaded by

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a.
(If the MoU for externship is undertaken with more than one institutes then the copy of all Applicant Hospital
MoU should be scanned in a single pdf file. Multiple Upload option for similar kind of

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document is not available.)

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Date:

Place:

Signature with official stamp of Administrative Head of the

Signature of the Head of the Department (With Official
Institute/Hospital
Stamp)
(Authorized signatory on behalf of applicant hospital)
Name:___________________________
Name:____________________________
Designation:_____________________
Designation:_____________________

Unique Bar-Coded Application Form

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