Faculty Proforma for the LLRM Website

Photo (Passport Size)

1. Name: .......................................................................................................

2. Qualification: ............................................................................................

3. Fellowships: ..............................................................................................

4. Date of joining: ............................................................................................. ..........................

5. Date of Birth: .....................Month: ...................................Gender: ...................

6. Designation: .................................................................................................................................

7. Department: ................................................................................................................................

8. Specialization: ..............................................................................................................................

9. Area of Interest: ...........................................................................................................................

10. OPD days: .....................................................................................................................................

11. OPD Room No.: ..................................................................................Timings: ..............................

12. Super speciality clinic: ..........................................................Room No / ward No. : .......................

13. Super speciality clinic days.......................................................Timings: ......................................

14. Awards: .......................................................................................................................................

a. International

b. National

c. State level

d. District Level

15. Achievements:

a. Publications (Index/Peer reviewed): ..............................................................................

Sl. Title of Article Journal Year/Month

No.
b. Publications (Non indexed): ..........................................................................................

Sl. Title of Article Journal Year/Month

No.

c. Books/Book Chapters: ....................................................................................................

Sl. Author/s Title Publisher Year of Page No.

No. publication

d. Invited Oral Presentations:...........................................................................................

Sl. Title Title of conference/seminar Year of publication Publisher

No.

e. Research Presentations (Oral): National................International............................

Sl. Title of the Title of Year of publication Publisher

No. paper conference/semi
nar volume

f. Research Presentations (Poster): National................International...............................

Sl. Title of the Title of Year of publication Publisher

No. paper conference/semi
nar volume
g. Others : ……………………………………………………………………………………………………………………………..

16. Research Work : …………………………………………………………………………………………………

a. Research guidance : Awarded Submitted Ongoing

……………………. ……………………… …………………..

b. Ongoing Thesis : ……………………………………………………………………………………………….

SI No. Title of the Chief/Co- Date of Expected date

Project investigators Commencement of completion

c.Other ongoing projects : ………………………………………………………………………………………………………………………………………….

17. Life Memberships : ……………………………………………………………………………………………………………………………………………………

18. Grants received : ……………………………………………………………………………………………………………………………………………………….

19. Other Corporate responsibilities

a. In LLRM …………………………………………………………………………………………………………………………………………………………………………………….

b. In Other Societies ……………………………………………………………………………………………………………………………………………………….

20. Community Services : ……………………………………………………………………………………………………………………………………………….

21. Social Services : ……………………………………………………………………………………………………………………………………………………….

22. Previous Appointments : …………………………………………………………………………………………………………………………………………

23. Email : ……………………………………………………………………………………………………………………………………………………………………………………

24. Website : ………………………………………………………………………………………………………………………………………………………………………………

25. Phone/Mobile No. : ……………………………………………………………………………………………………………………………………………………….

26. Fax : …………………………………………………………………………………………………………………………………………………………………………………………

27. Address for Communications : ……………………………………………………………………………………………………………………………..