CHRISTIAN MEDICAL COLLEGE, VELLORE, INDIA
DEPARTMENT OF INFECTIOUS DISEASES
FELLOWSHIP IN GENERAL INFECTIOUS DISEASES AND ANTIMICROBIAL STEWARDSHIP
APPLICATION FORM 2023-24
PART-A
FULL NAME: __________________________________________________ Affix a
Photograph
DATE OF BIRTH: __________________________ SEX: __________ NATIONALITY: ___________________
PERMANENT ADDRESS:
_________________________________________________________________________ ___________
_____________________________________________________________________________________
PRESENT ADDRESS:
_____________________________________________________________________________________
_____________________________________________________________________________________
Your preferred address for communication:
PERMANENT ADDRESS PRESENT ADDRESS
TELEPHONE: ______________________ MOBILE NO**: _______________________________________
E MAIL ADDRESS**:
______________________________________________________________________
(The fields marked ** requires extra attention while filling)
MCI /STATE REGISTRATION NO: ______________________
Repeat Applicant for FGID Course: Yes/No
If Yes, Year(s) Applied: ______________________________
A. EDUCATION:
INSTITUTION& ADDRESS PERIOD DEGREE
UNIVERSITY FROM TO
(DATE) (DATE)
PG Degree
PG Diploma
MBBS
Pre-Medical
AWARDS & HONORS (If any)
_______________________________________________________________________
_______________________________________________________________________
B. WORK EXPERIENCE:
1) Mention your current Institution you are working & position
______________________________________________________________________________
Date of Joining: ______________________
Firm: Government Private Armed Forces Mission
2) Previous Employments:
INSTITUTION & ADDRESS PERIOD
SL.NO (Most recent ones first) DESIGNATION
FROM (DATE) TO (DATE)
1
C. PLEASE ANSWER THE FOLLOWING QUESTIONS IN A PARAGRAPH EACH:
(Please attach separate sheets)
1. Explain in 100 words, how doing this course will enhance/change your practice?
2. This course will involve regular study, completion of assignments and patient evaluation, in
addition to attending the two contact sessions. Do elaborate on how you would create
sufficient time (2-3 hours in a week) for study, in addition to your current responsibilities.
3. Explain your commitment to work in the same hospital.
PART – B
Hospital description
1. Total Number of Beds: __________
2. Total Number of Departments: __________
3. Names of Departments:
4. Daily Average bed occupancy__________
5. Average Number of outpatients/day ___________
6. Total Number of staff:
Doctors MBBS________
PG’s ________
Nurses Graduates________
Certificate________
Lab technicians________________
Physiotherapists_______________
X-ray technicians______________
Counselors/Social workers___________________
Pharmacists _______________
7. Facilities available:
Radiology (list of tests available)
1___________________ 2________________ 3 ______________
4____________________ 5 ________________ 6 _____________
Operation Theatre________
Labor room_________
Laboratory facilities (list of major test done)
1___________________ 2________________ 3 ______________
4____________________ 5 ________________ 6 _____________
Microbiology culture facility - Y/N
8. Do you have access to computers and internet? Yes______ No_____
DECLARATION
I declare that the information given in my application form and any additional
information provided in support of my application is true and complete to the
best of my knowledge and belief and also I am aware and understand that this is
purely an institution run course and not affiliated to any University or National
and International accreditation bodies.
Candidates Signature:
Name of the Candidate:
PART – C
SUPPORT FROM THE HOSPITAL
How supportive would you be of the proposed course of the applicant? In what ways
would you provide support the candidate? Please be specific as possible (time,
recourses, administrative support and manpower)
Applicant’s Name ____________________________________________
Hospital ____________________________________________
Nominating Officer’s name) ____________________________________________
Designation ____________________________________________
Phone ____________________________________________
E-mail ____________________________________________
Address ____________________________________________
____________________________________________
____________________________________________
____________________________________________
Date: _____________
Nominating Officer’s Signature __________________________________________
POINTS TO NOTE:
The application form should be filled up legibly.
Copies of MBBS and all other degree & registration certificates should be attached with
the application. Incomplete applications will be disqualified.
The candidates should bear their expenses for attending the contact programs towards
travel, boarding and lodging.
The last date for the receipt of completed application forms is 31 st March 2023
The short listed candidates shall be intimated in the month of April/May 2023 for
interview
The short listed candidates would be required to sign an undertaking that, they would
comply with all the requirements of the course, before they are considered for the final
selection.
The organizers may hold an interview of short listed candidates.
The conduct of the interview shall be at the sole discretion of the organizers.
The course is likely to commence in July/August 2023
INSTRUCTION
All completed application forms need to be sent with the following documents:
1. A copy of your resume / CV
2. Attested copies of the degree & registration certificates
3. Proof of paid application fee & please email the transaction details to
[email protected] as well.
All the stated documents need to be sent to:
COURSE CONVENOR (FGID program)
DEPT OF INFECTIOUS DISEASES
CHRISTIAN MEDICAL COLLEGE
SP COMPLEX 4TH FLOOR
IDA SCUDDER ROAD, VELLORE-632004,
TAMILNADU, INDIA
OR
Email it to [email protected]
