1
Hospital Profile:
2
Contact Details:
3
Services at Hospital:
Hospital Name
*
:
State
*
:
--Select--
ANDAMAN
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA & NAGAR HAVELI
DAMAN & DIU
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU & KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHADWEEP
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
NCT OF DELHI
ODISHA
PUDUCHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTAR PRADESH
UTTARAKHAND
WEST BENGAL
District
*
:
--Select--
I
d
City
*
:
Taluk/Mandal :
--Select--
I
d
Address
*
:
Landmark :
Pincode
*
:
Site Type
*
:
--Select--
Model C
PPP-A
PPP-B
Contact Person Name
*
:
Contact Person Designation :
Contact Person Mobile :
Registered Mobile
*
:
Contact Number :
FAX Number :
Email Id :
Website Address :
Year of Hospital Registration
*
:
Hospital Management Type :
--Select--
Private,faith based missionary
Private,for profit
Private,for philanthropy(Charity, Trust, Society)
Others
Types of ICTC :
--Select--
Single kit testing site
Three kit testing site
Type of facility :
--Select--
Private Medical college
Private Hospital
Private Maternity Hospital
Private Nursing Home
Private Laboratory
Private multispecialty hospital
Private clinic
Government hospital
Others
No. of Hospital Beds :
--Select--
<10
11-25
26-50
51-75
76-100
101-200
Above 200
No.of Delivery Per Month :
Do you have in-house laboratory in your hospital? :
Remarks :
No. of Lab Tests/Month :
Specialty :
Is your lab associated with any government health programs/projects :
Important Information :
At present, is your hospital attached to any of following government projects? :
Integrated Counselling and Testing Centre
TB/RNTCP – DOTS Centre
TB/RNTCP – Sputum collection centre
TB/RNTCP – Laboratory services
Disease surveillance
Health Insurance
Maternal and Child Health
Family Planning
Baby Friendly Hospital Initiative
Non-communicable diseases
Others
Specialty :
O&G
Medicine
Surgery
Orthopaedics
Pediatrics
ENT
Ophthalmology
Skin
STD
TB
General practitioner
Super specialty department
Others
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