Annexure-1

APPLICATION FORMAT FOR HEALTH CAMPS

Organisation Profile :

Name of the Organization:

Types of Organisation:
Regd. Society / Trust/ Corporate House/ Professional
Bodies / Association/ any other (specify)

Registration details*
a. Registration number:

b. Year of registration :

c. Types of registration:

* Registration certificate enclosed.

Name of the Chief Functionary:

Registered office address with phone,

fax number and email ID:

B. Work experience in relevant field :

c. Major achievements :

Types of camp | Date Purpose Beneficiaries (in Whether follow Whether any adverse effect
organised nos) up done, if so, noticed during follow up
for how long ?
 B. Proposal for Organization of Health Camp/s

1. Title of the camp

2. No. of camps proposed

3. Targeted beneficiaries

4. Expected beneficiaries per camp (in nos.) :

5. Location / Site of the camp : [__]institution Level * / [ } Field Level

Detail address of the site

* Authorization certificate from the head of the respective institution enclosed

6. Justification for organizing camp/s** (Provide disease burden status and evidences similar initiatives if
any):

** Supporting scientific evidences enclosed for new activities

7. Relevant experience in organizing such camps if any & performance:

8. Types of Service / Service Components

Category Details of Implementation modalities / Techniques to be used if any

Awareness

Screening /

Diagnosis

Treatment

Follow up

Any other
 9. Quality and patient facilities (clean drinking water, sanitation, sitting arrangement, toilet etc.) to be
provided.
-

10. Management plan for any possible complications/ adverse effects if any)

11. Critical manpower proposed to be engaged / mobilized

Experience in similar areas

Category Name Educational Qualification
(In Years }

Professionals

12. Estimated budget

Broad head Cost Estimates Source of Fund

13. Expected outcomes / Outputs (both quantitative & qualitative aspects to be mentioned)

This is to certify that above mentioned information is true.

Signature of the Chief Functionary

Date:
es als Annexure-i(a)

Recommendation Format for Health Camps

1. Camp Details:

1.1 Nature of Camp: New* On going

* Not implemented yet as part of any programmes under H&FW Deptt. Govt. of Odisha.

1.2 If new, supporting scientific evidence furnished: Yes No

1.3 If on going, proper justification given is
For organisation of the camp at the proposed area: Yes No
2. Status and performance of the implementing organisation

2.1 Registered Body: Yes No

2.2 Performance in previous assignment if any:

3. Feasibility of the proposal

3.1 Status of proposal: Complete** Incomplete

** Furnished in prescribed format along with all supporting documents.

3.2 Critical HR*** to be engaged/ mobilised: Detailed plan furnished Not furnished
*** Appraisal committee to be decide based on the need

3.3 Location of the camp site : Suitable Not suitable

3.4 Quality Assurance measures defined:

3.5 Scientific evidence furnished for new/ innovative initiatives: Yes No
4. Any other observations

Decisions of the Appraisal Committee:

Recommended for approval

Recommended for approval by State

Research Ethical Committee (In case of
requirement)

Not Recommended

Signature of the Chairperson of DQAC / Collector

i. Criteria for recommendation: No negative response found for the indicators mentioned above
ii. Criteria for recommendation to ethical committee for final approval: The proposal is new/ innovative in
nature and scientific evidences furnished as required
 Annexure-1(b)

Undertaking by the Organisation

eilu bas cbielaiidaetaptendonceapearearnree (Chief Functionary of the Organization),

sienna gs cen enbs atin ee ca blo eit Neeiererleeeree ERS? WIRING: and “widdreeses Of the registered
organization) do hereby solemnly affirm and sincerely state that;

a) The organisation is hereby agreed to undertake the programme i.e. weowswncene samuauuanaecn sees
as per the defined terms of reference defined for organising health camps
c in thedistrict.
b) The organisation will adhere to all the standard treatment guidelines/SOP defined for the
proposed programme.
¢) The organisation will not use any medical technology for screening/diagnosis of the patients,
which is not approved by the competent authority/ regulatory body.
qd) The organisation will be held responsible for any type of adverse effects arise during or after
the camp and will take necessary follow up action for effective management of such
incidence/s. The organisation will also be legally liable for any compensation or penalty
awarded by the appropriate authority related to the camp.
e) | or any other office bearer on behalf of the organization has not been convicted by any
Government/ Agency/Court in India or abroad for any criminal offence.
f) The organization has not been blacklisted by any Government (State or Central) Department or
Agency in India, which is in force during the currency of the contract.
8) There is no previous case of mis-management or adverse effect in any camps organised by the
organisation, so far.

| further affirm that, in case of any such evidence in contradiction to above declaration come to the
notice then | and my organization is liable for legal action.

Dated thissassnssusscmesis
DOV OF aii cists. ney ef Dereal!

Name and Signature of the Applicant