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CUMULATIVE RECORD OF Auxiliary Nursing & Midwifery Name (In Block letters as entered in XII- Mark list): --------------------------------------------------------------------------Sex:

M / F Date of Birth: --------------------------- Nationality: --------------------------Religion: --------------------

Affix Passport Size Photograph

Community: FC / BC / SC / ST / Blood Group: -----------------------Name of Parent / Guardian Address: : ------------------------: Permanent Temporary

----------------------------------------------------------------------------------------------------Identification Marks: 1. ------------------------------------ 2. ---------------------------------------------Academic Qualification:

--------------------------------------------------------------------------------------------------------------------------

Higher Secondary Examination: Certificate No: -------------------- Date: ------------------Total Marks: ------------- No of attempt: --------Date of Admission: ---------------------------------- Admn. / Regn. No / Year: ----------------------------Scholarship availed: Source: ---------------------- Amount: -------------------- Duration: ---------------------Bank Loan availed: Source: ---------------------- Amount: -------------------- Duration: ---------------------SUBJECTS WITH HOURS OF PLANNED INSTRUCTIONS GIVEN IN ANM NURSING S.NO Subjects No. Of No. of Hrs. as Theory S.NO per INC Hrs Given Subjects No. Of No. of Hrs. as per Theory INC Hrs Given

I-Year 1. 2. Community Health Nursing Health Promotion A. Nutrition B. Human body and Hygiene C. Environmental Sanitation D. Mental Health Primary Health Care Nursing I A. Infection and Immunization B. Communicable Disease C. Community Health Problems D. Primary Medical Care E. First Aid and Referral Child Health Nursing 65 55 35 40 45 75 85 40 60 180 1. 2.

II-Year Midwifery Health Care Management 360 75

TOTAL

435

3.

180

TOTAL

860

SIGNATURE OF THE CLASS CO-ORDINATOR

SIGNATURE OF THE PRINCIPAL

CLINICAL AND FIELD EXPERIENCE HOURS

Duration of the course: 1 1/2 Years

Wks Given

Hrs allotted by INC

Night duty

S.N

Hrs Given

Year

Area clinical /field

I 1 Community Health Nursing 2 Health Promotion 3 4 Primary Health Care Nursing I Child Health Nursing TOTAL II 1 2 Midwifery Health Care Management TOTAL 560 60 620 130 220 440 200 990

Sign of I year Co-coordinator

: ----------------------- Date: -------------------- Signature of the principal-------------- Date: -----------------

Sign of II year Co-coordinator

: ----------------------- Date: -------------------- Signature of the principal-------------- Date: -----------------

CLINIICAL POSTINGS (HOSPITAL @ COMMUNITY)

S.NO Year

Clinical setting

Bed strength

Duration

allotted by INC

Weeks

S.NO Year

Clinical setting

Bed strength

S.N

Duration

VACATION AND HOLIDAYS Type of leave I Year Days II Year Days Annual Vacation Sick Leave Preparatory Leave Extraordinary Leave Leave without stipend S.No Name of the vaccination Date

VACCINATION

WORK ASSESSMENT Assessment Work Grade: A- Excellent, B- V.Good, C- Good, D- Average, E- Poor A : >85%, B-75% to 84%, C- 65% to 74%, D- 50% to 64%, E- <50% I Year II Year

SIGNATURE OF PRINCIPAL UNIVERSITY EXAMINATION MARKS I YEAR Board Examination Regular Pape r Internal- 25 External 75 Internal 100 External 100 200 Internal 100 200 Internal 100 100 External 100 200 Internal 100 External 100 200 Internal 100 External 100 100 External 100 200 Total Subjects Month/Year Theory Supplementary-I Month/Year Supplementary-I Month/Year Regular Month/Year Practical Supplementary-I Supplementary-II Month/Year Month/Year

Total

Total

Total

Community Healt Nursing

Total

Practical-1 Community Health Nursing and Health Promotion

II

Health Promotion

III

Primary Health Care Nursing I Child Health Nursing Practical2Child Health Nursing

IV

Total

Subjects

SIGNATURE OF THE CLASS CO-ORDINATOR

SIGNATURE OF THE PRINCIPAL

UNIVERSITY EXAMINATION MARKS II YEAR Board Examination Regular Theory Supplementary-I Supplementary-I Regular Practical Supplementary- SupplementaryI Paper Subjects Month/Year
Internal- 100 External 100 200

II Month/Year
200 Internal 100 External 100 200 Total

Month/Year
Internal 100
External 100

Month/Year Total 200


Internal 100 200 External 100

Month/Year
Internal 100 External 100 200

Month/Year
Internal 100 External 100

Total

Total

Total

Subjects

Midwifery

Practical-I Midwifery

II

Health Centre Manageme nt

Primary Health Care and Health centre Management

SIGNATURE OF THE CLASS CO-ORDINATOR

SIGNATURE OF THE PRINCIPAL

Note: certificate will be issued by Kumouan University after successful completion of course.

Certificate Number: ------------------ RN: ---------------------- RM: ---------------------- Date of registration: -------------------Special Notation: -----------------------------------------Aggregate Marks: -------------------------- Division: --------------------- School Rank: ------------------ State Rank: ----------------Distinction: 80% and above, First Division: 70% to 79%, Second Division: 60% to 69% Pass: 50% to 59%

Signature of the class co-coordinator

Signature of the principal

Total